Preoperative Clearance for Eye Surgery in Diabetic Nephropathy Patients on Dialysis

Cardiovascular Risk Assessment

The American College of Cardiology recommends obtaining a detailed cardiovascular history, including coronary artery disease, prior revascularization, arrhythmias, cerebrovascular events, and peripheral arterial disease, for diabetic patients on dialysis undergoing eye surgery 2
The American Diabetes Association suggests screening for cardiac autonomic neuropathy (CAN) which is common in patients with diabetic nephropathy and significantly increases perioperative risk—look for permanent tachycardia, QTc >440 ms, orthostatic hypotension, or unexplained hypoglycemia 3, 2
The American Heart Association recommends performing ECG to identify ischemia, silent myocardial infarction, arrhythmias, or prolonged QTc interval 2
Calculate Lee score (revised cardiac risk index) and assess functional capacity—if Lee score ≥2 and functional capacity <4 METs, refer to cardiology for ischemia testing even for eye surgery, as recommended by the American College of Cardiology 2
Consider cardiac testing if macroproteinuria, other arterial damage, or coronary calcium score >400 Agatston units are present, as silent myocardial ischemia is common in this population, according to the American Heart Association 3, 2

Measure current GFR and albumin/creatinine ratio (ACR) to assess severity of diabetic chronic kidney disease, as recommended by the National Kidney Foundation 1, 5
Avoid all nephrotoxic agents in the perioperative period, as suggested by the American Society of Nephrology 1, 5
Plan for mean arterial pressure maintenance of 60-70 mmHg (or >70 mmHg if hypertensive) during surgery to maintain renal perfusion, according to the American Society of Anesthesiologists 1, 5

Measure HbA1c preoperatively with target <7% for optimal perioperative outcomes, as recommended by the American Diabetes Association 5
Hold metformin on the day of surgery (if still prescribed despite renal failure), as suggested by the American Diabetes Association 5
Continue basal insulin at 75-80% of long-acting dose or 50% of NPH dose—never stop completely in Type 1 diabetes due to ketoacidosis risk, according to the American Association of Clinical Endocrinologists 5

Verify current antihypertensive regimen includes ACE inhibitors or ARBs unless contraindicated, as recommended by the American Heart Association 1, 5
Target blood pressure <140/85-90 mmHg preoperatively, according to the American Heart Association 1, 5

Inform anesthesia team about need for pharmacokinetic adjustments due to chronic renal failure, as suggested by the American Society of Anesthesiologists 1, 5
Plan for postoperative monitoring in high dependency unit if cardiac autonomic neuropathy is confirmed by two abnormal tests or if symptomatic, according to the American College of Cardiology 3, 2