Comparing with general population, a higher mortality rate has been confirmed in patients with hip fractures associated with end-stage renal disease accepted hemodialysis. Among end-stage renal disease patients, in fact, hemodialysis is associated with a 61% higher risk of hip fracture than peritoneal dialysis which was proved by Boonpheng B et al. in their meta-analysis of observational studies about risk of hip fracture in patients on hemodialysis versus peritoneal dialysis[8]. The patients with end-stage renal disease underwent hemodialysis usually had one or more other diseases such as hypertension, diabetes mellitu, coronary disease, hyperparathyroidism, and osteoporosis. These patients carry significantly higher risks of perioperative morbidity and mortality due to multiple co-morbidities, regardless the type of surgery. Thus, in these dialysis population, it remains a challenging problem for therapeutic strategies in perioperative period[1, 7]. Our study clarify the treatment algorithm of a hip fracture in patients with end-stage renal disease who are on chronic hemodialysis in terms of retrospectively analysis of six subjects based on their medical messages. This comprehensive treatment algorithm consist of preoperative treatment of methods, intraoperative management strategies, and postoperative therapeutic programs. These methods includes planned hemodialysis, prophylactic anticoagulation, anti-osteoporosis therapy, management of blood pressure, blood sugar, and hyperparathyroidism. Besides, respiratory disease cardiovascular or cerebrovascular disease and renal anemia should also accepted effectiveness of therapy.
In general, the planned perioperative dialysis is required to correct the fluid status and electrolyte abnormality. It is still unclear about the appropriate timing of preoperative dialysis due to the scarcity of clinical data. Nevertheless, removal of the uremic toxins dependent on hemodialysis within 24 hour prior to surgery and after postoperative time that can reduce risk of morbidity and mortality. Previous study reported that the simple scheduling policy of perioperative hemodialysis is effective at reducing both cost and unnecessary perioperative risks for patients[9]. On another, Renew JR et al. suggested that hemodialysis within 24 hour prior to surgery was associated with a lower potassium level on the day of surgery[10]. Our six patients accepted planned perioperative dialysis, no clinical complications were observed by us on duration of hospital stay. And also, the level of uremic, fluid status and the level of electrolyte were at a reasonable level.
With regard to prophylactic anticoagulation, a correct assessment of the underlying bleeding should be done, especially, for early gastrointestinal bleeding or potential encephalorrhagia.
Unfractionated heparin is recommended to be used as the first choice anticoagulant for hemodialysis. Notably, low molecular weight heparin is not suitable for patients with hip fractures associated with end-stage renal disease accepted hemodialysis[11.12]. Considering the heparin effect lasts 4 hours, elective surgery should be scheduled at least 6 hours after dialysis to avoid perioperative bleeding when unfractionated heparin is used during hemodialysis. Heparin-free dialysis is excluded within 24 hour prior to surgery in our recommendation. Besides, it is critical importance to perform regular monitoring of activated partial thromboplastin time and inspection of fecal occult blood[12].
As an usual consequence of end-stage renal disease, secondary renal osteodystrophy often was observed in these subjects. In fact, it is complex and multi-factorial to pathophysiology of renal osteodystrophy. One study found following factors were associated with a low bone mass in hemodialysis patients, that included an advanced age, low body weight, low serum albumin level, and high alkaline phosphatase and parathyroid hormone levels[13]. Decreased glomerular filtration often leads to undue phosphate retention causing hyperphosphatemia, which results in decreasing in 1, 25 di-hydroxy vitamin-D synthesis. Finally, these in turn causes hypocalcemia[14]. At same time, higher phosphate levels in gastrointestinal cell cytoplasm matrix impede to absorption of calcium from gastrointestinal tract, which adds to the insult and further exacerbates the hypocalcemia. In patients on dialysis, hypocalcemia inverse stimulation brings about hyperactivity of the parathyroid glands, and hyperphosphatemia directly stimulates parathyroid hormone secretion[14, 15]. The above factors maintains a persistent stimulus for parathyroid hyperplasia. A resultant secondary hyperparathyroidism tends to compensate for the low serum calcium levels by leeching calcium off the bones. The overall result of this vicious cycle is that the bone structure, especially in vertebra, pelvis, and neck femur regions, is significantly weakened and is, hence, rendered susceptible to pathological fractures[16]. Thus, in patients with end-stage renal disease requiring calcimimetics, calcitriol, vitamin D analogs, or a combination of calcimimetics with calcitriol or vitamin D analogs is suggested[2]. However, a majority of anti-osteoporosis agents should be avoided to use for patients with end-stage renal disease, except that denosumab due to its action mechanism which is cleared by the reticuloendothelial system and not the kidney[17, 18].
It is extremely important to tailor of blood pressure for patient with end-stage renal disease to reduce perioperative morbidity. Patients with end-stage renal disease accepted tailor treatment of blood pressure, whose blood pressure should be less than 130/80 mmHg, that was recommend by KDIGO Clinical Practice Guidelines[19]. The usage of one or more following anti-hypertension agents were recommended by our study and previous literature, which consisted of angiotensin converting enzyme inhibitor, angiotensin receptor blocker, and calcium channel blockers[20].
Heart failure combined systolic heart failure and diastolic failure, as the final forms cardiovascular disease in end-stage renal disease patients, to which need also be payed attention by orthopedist. When acute pulmonary edema or congestion occurs in patients preserved micturition, an suitable intravenous diuretics should be initially administered by physician[21]. Maintenance of systolic blood pressure lies between 85mmHg and 115mmHg is recommendation. In respectively, continued administration of dobutamine or a vasodilator, nitroglycerin is necessarily needed in patients with a systolic blood pressure < 85mmHg or a systolic blood pressure > 115mmHg. Moreover, consideration of emergency hemodialysis is required when the hemodynamics are not stable.
Asymptomatic or concealed respiratory diseases associated with end-stage renal disease is an important yet under-recognized condition and can lead to life-threatening complications. Also, pneumonia was needed to usage of sensitive antibiotics, effective atomization. Pulmonary hypertension was needed to therapy of endothelial receptor antagonists, phosphodiesterase inhibitors or prostacyclin agonist[22]. It is worth noting that cautious use of diuretic is needed as they lead to dangerous hypotension with regard to therapy of pulmonary hypertension.
In patients with diabetic end-stage renal disease, careful glucose monitoring is important due to difficulty of prediction insulin requirements, and increasing risk of hypoglycemia[23]. The increased mortality of patient accepted hemodialysis has been reported by Ricks et al., when HbA1c levels were less than 6.0% or more than 8.0%[24]. Even though, the clinical significance of this condition remains unclear. The findings indicate that these patients with HbA1c levels < 6.0% have a poor outcome from the view point of burnt-out diabetes[25]. Thus, A target range of HbA1c in end-stage renal disease patients of 6.0–8.0% was recommended, especially in diabetic dialysis patients[26]. As mentioned above, insulin is preferred for most hemodialysis patients who require medication, even though oral agents are acceptable alternatives. In fact, many diabetes medications including metformin are contraindicated, if estimated glomerular filtration rate falls below 30 ml per minute per 1.73 m2[27, 28].
End-stage renal disease is an independent risk factor for cerebrovascular events, and increased mortality[29, 30]. The incidence of ischemic stroke is 2.5-fold higher than in age and sex-matched controls in end-stage renal disease patients on hemodialysis[31]. Antiplatelet agents have not shown a clear benefit for secondary stroke prevention, but aspirin may reduce incident stroke in hypertensive end-stage renal disease patients. Observational data suggests that apixaban being associated with lower stroke risk and fewer major bleeding events[32]. These patients are at high risk for cerebrovascular morbidity and mortality. However, despite being well tolerated, statins therapy evaluated in large clinical trials in this patient population has generally failed to significantly reduce this disease burden. The cause of cerebrovascular death is not always atherosclerotic in nature and may depend on the modality of renal replacement therapy[33]. In our cases, all patients accepted regularly oral statins therapy because of plaque of carotid artery.
As a commonly diagnosed complication among patients with end-stage renal disease suffering with hemodialysis, anaemia should be treatment as soon as possible, if not, that may affect patient quality of life. Several causes for anaemia in these population have been reported, including iron deficiency, utilizing of iron, and dietary restrictions[34]. Thus, the therapeutic protocol of anaemia consist of additional infusion of iron treatment, additional recombinant human erythropoietin treatment and red blood cell transfusions. Finally, any patients will eventually require treatment with erythropoietin or similar products that are given by injection. The need for red blood cell transfusion remains for patients who require an immediate increase in their red blood cell mass due to symptomatic anemia or hip replacement surgery. Caution of hyperkalemia or transfusion-associated circulatory overload occurs in patient with end-stage renal disease. On perioperative duration, in fact, strategy to prevent post-transfusion hyperkalemia or circulatory overload is accepted planed hemodialysis[35].