Introduction
Chronic renal failure is a progressive condition commonly caused by hypertension, diabetes mellitus, glomerulonephritis, drug toxicity, or heavy metal exposure. In critical renal dysfunction, such patients need dialysis that severely limit the applicability of abdominal surgery. However, recent advances in surgical treatment and perioperative care greatly improved survival outcomes in these patients.1,2 Therefore, these patients are much more likely to undergo surgery for other diseases, including major abdominal surgery.3,4 Nevertheless, those who have been diagnosed with end-stage renal disease (ESRD) remain at elevated risk of cardiovascular complications and may also have impaired immune system and coagulation, which significantly affect recovery from major abdominal surgery.5,6 As a result, a significant proportion of end-stage renal failure patients subjected to various non-elective abdominal surgeries die due to peri- and post-operative bleeding complications.7 The ESRD as a comorbidity is associated with twice longer in-hospital stay and 2-to-3 times higher peri- and post-operative mortality in patients subjected to endovascular aneurysm repair.8 In patients with ESRD, which have hemodialysis or hemofiltration and were subjected to laparoscopic ventral hernia repair, the risk of post-operative pneumonia and sepsis was significantly higher.9 However, in selected ESRD patients with carefully evaluated post-operative risks, the outcomes of laparoscopic abdominal surgery may be beneficial.10 In addition, the post-operative outcomes and complications may depend on the preceding history of hemodialysis. For example, one report showed that three patients with ESRD and having dialysis for (on average) >7 years may survive the surgery, while one of the patients died 21 months later from another disease.11 Nevertheless, the considerations about overall risk are likely contributing to persisting reluctance of using major abdominal surgery in such patients.
In the Central Asia, the applicability of this surgical approach for such specific patients is extremely limited due to the high risk of negative outcomes and, in particular, because of the lack of highly experienced surgeons as well as due to the difficulties related to the transportation of dialysis patients to the clinical setting. This report presents the case of a 71-year-old female supported by hemodialysis and diagnosed with pancreatic head cancer who had severe comorbidities (diabetes mellitus type 2, chronic hypertension, chronic kidney disease), and who underwent a successful pancreaticoduodenectomy.
Case Presentation
The 71-year-old female patient of Kazakh nationality was admitted to the surgical department of National Scientific Medical Center, Astana, Kazakhstan, complaining of prolonged nausea, vomiting after eating or drinking, persistent thirst, unstable hemodynamics, and a weight loss of 20 kg in the past month. Urine output was 200–300 mL/day indicating oliguria. Hyperglycemia episodes and general weakness were noted. The patient was on permanent dialysis for approximately 5 years before treatment.
Abdominal CT scans (Figure 1) showed the following: i) hepatomegaly, ii) dilation of common bile duct up to 22.9 mm wide, intrahepatic ducts up to 8.2 mm wide, iii) mass in the head of the pancreas sized 4.7×3.3 × 3.8 cm, iv) Wirsung Stasis (Wirsung duct up to 7.7 mm wide), v) chronic atrophic pancreatitis, vi) pancreatic cysts up to 6.6 mm in diameter, and vii) cysts of both kidneys, 10.0 mm and 8.0 mm in diameter on the right and left, respectively. Stenosis of the renal arteries on both sides was found. Percutaneous transhepatic cholangiostomy was performed.
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Figure 1 Preoperative imaging findings (CT, July 2024). Abdominal CT revealed a mass in the head of the pancreas measuring 4.7×3.3 × 3.8 cm, with signs of local invasion and compression of the surrounding structures (shown as the yellow contour). (A) – axial CT plane, (B) – frontal CT plane.
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Past medical history revealed insulin-dependent diabetes mellitus. Also, chronic kidney disease (CKD), diabetic nephropathy, arterial hypertension were present for 19 years. Laboratory tests showed that creatinine level was at 1171.30 μmol/L (the normal range for females is 49 to 90 μmol/L). There was also anemia with hypocalcemia: erythrocytes – 2.35 × 1012/L, hemoglobin – 71.00 g/L, calcium level in blood plasma – 1.8 mmol/L.
A consultation was held, and a decision was made to perform surgical treatment for vital indications. In the preoperative period, two hemodialysis sessions were performed four and two days before surgery. Also, taking into account the remarkable anemia (hemoglobin – 71 g/L), a transfusion of one dose of washed red blood cells (Blood Component, 260 mL) four days before surgery and just after hemodialysis session was performed. The day before the operation, the results were the following: erythrocytes 2.91 × 1012/L, hemoglobin – 87.00 g/L, creatinine – 542.78 μmol/L.
The patient was taken for surgery. Laparotomy and revision were performed. During revision, the tumor of the head of the pancreas was up to 4.0 × 3.0 × 3.0 cm. Taking into account the preoperative and intraoperative data, the situation corresponded to a malignant neoplasm of the head of the pancreas. Pancreaticoduodenectomy was performed. The duration of surgery was 280 minutes and it went without complications.
On the next day after surgery, control blood tests were taken. Creatinine level was 364.02 µmol/L, hemodialysis was recommended. During the postoperative period, the levels of glucose and electrolytes were carefully monitored. The patient was receiving the following treatment: antibacterial therapy (meropenem 500 mg twice a day), gastroprotective therapy (omeprazole 40 mg intravenously), anticoagulation therapy (enoxaparin injection i.p. 40 mg), parenteral feeding, pain management and correction of electrolyte abnormalities, which were strictly monitored by taking arterial blood gas and electrolyte analysis four times a day. In the early postoperative period, mild hyponatremia was observed, which was corrected by the administration of 10% sodium chloride (200 mL). The patient’s blood pressure was strictly monitored, in perioperative period patient received oral moxonidine and bisoprolol under pulse and blood pressure control.
Taking into account the patient’s stage 5 chronic kidney disease, chemotherapy was contraindicated, and patient did not receive it. Hypoproteinemia with total protein level of 46.99 g/L was noted in the postoperative period, and therefore albumin transfusion was performed. Taking into account the anemia conditions (erythrocytes – 2.70 1012/L, hemoglobin – 81.00 g/L, hematocrit – 24.70%), a blood transfusion was performed. Hemodialysis was performed 3 days before the operation, and then three hemodialysis sessions were performed in the postoperative period: 2nd, 9th, and 13th days after the operation. Intestinal function was restored on the 5th day after the operation, early enteral nutritional support was performed through a jejunostomy. Electrolytes were normalized on the 10th day, the hemoglobin level has reached 96 g/L, and there were no indications for blood transfusion; creatinine level was 546.20 μmol/L by the time of discharge. The patient was discharged on day 14 post-surgery in a satisfactory condition for further outpatient treatment.
Final histopathology revealed endo-exocrine cancer of the head of the pancreas with ulceration, invasion into the muscular layer of the duodenum, formation of a mucinous cyst, metastasis to regional lymph nodes. The focal erosions were also observed with chronic cholangitis, papillitis, and serous-hemorrhagic omentitis.
Five months later, the patient underwent an MRI of the abdominal organs, which showed soft tissue consolidation in the postoperative area as well as ascites (Figure 2). On 7 months post-operative follow-up, the MRI of the abdominal organs (Figure 3) revealed negative dynamics due to multiple focal liver lesions, most likely metastatic (mts). Significant ascites persisted. By summer 2025, the patient was alive according to the available information in national healthcare registry, but we were unable to perform diagnostic observations for further complications as well as progression of the oncological lesions.
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Figure 2 MRI follow-up 5 months postoperatively (February 2025). Findings indicate soft tissue consolidation in the postoperative area. Ascites is also noted.
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Figure 3 MRI follow-up 7 months postoperatively (the end of April, 2025). Findings indicate negative dynamics due to multiple focal liver lesions, most likely metastatic (mts, shown by yellow pointers). Significant ascites persists.
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Discussion
The number of patients with end-stage renal disease (ESRD) who need the long-term dialysis has been increasing in recent years.12 The most important chronic diseases that contribute to the increase are diabetes mellitus,13,14 CKD,15 and hypertension16 – the prevalence for all these diseases is steadily increased worldwide. This substantiate that the number of major surgical treatments in the patients requiring dialysis has also significantly increased.
The concomitant and/or post-operative complications are greatly affecting the outcome of surgical treatment in these patients. Among the most affecting, one would list cardiovascular complications, dysfunctions in vascular system resulting in hypo- and hypertension, diabetes mellitus, disorders in blood system, and disorders in immune responses.17,18 ESRD patients have coagulation disorders associated with uremic platelet, fibrinogen, and thrombin dysfunction,19,20 and are thus susceptible to bleeding. Immune function impairments like immune senescence and chronic inflammation are also occurring as the total amount of lymphocytes and phagocytes may change in parallel with the alterations in their activity.21 This leads to an increased risk of post-surgical infection and inflammation. In addition, the complications of pulmonary system may develop at higher risk.22,23 For example, the patients on hemodialysis have a higher incidence of complications in the postoperative period, in particular myocardial infarction, pneumonia, bleeding, septicemia, compared with the control group.24 Also, patients on dialysis have a much higher 30-day postoperative mortality.12 The duration of hospitalization and stay in intensive care are also higher in dialysis patients, partly due to infection-related complications.3,25 The same results were shown in a meta-analysis, where morbidity in the postoperative period was evaluated in the patients on chronic dialysis.18 According to their data, the risk of myocardial infarction and stroke was 2–5 times higher in patients on dialysis, regardless of the type of surgery performed. It has also been found that combined hypertension and diabetes in chronic dialysis patients resulted in higher postoperative risk of stroke, pneumonia, and septicemia, compared to the patients without diabetes or hypertension (but those may have one of the diseases).24 In addition, diabetes mellitus in aged patients provides increased chance of myocardial infarction associated with chronic dialysis compared to younger patients; similarly, the risk of stroke is higher in aged patients with coronary artery disease.3
Collectively, these data show that the presence of non-dialysis comorbidities (eg, diabetes mellitus) in aged patients contribute significantly to the elevated risks of poor outcome of surgical treatment. In other words, dialysis itself is not a dominating factor in perioperative morbidity in these patients.3,18 However, if we consider hepatic and pancreatic surgery, such operations are still rare in ESRD patients.25,26 This may be explained by the concern about operative and perioperative risks in such patients.27 Despite the improved safety of hepato-pancreatic resections in last years, such surgical treatments remain risky in terms of post-treatment morbidity and severe complications even in the patients without severe pre-operative comorbidities.25 In addition, substantial peri- and early post-operative fluid shifts are the common concerns in hepato-pancreatic resections, thus contributing to the complications related to the inability to accommodate to these fluids shifts. Therefore, pancreatic surgery is still one of the most complex surgeries, and there are many factors that influence the prognosis. Among the factors, renal failure plays a great role in the elevated risk of postoperative complications that may include cardiac arrest and require blood transfusion, as well as septic shock may develop. Many studies reported that such patients, ie, those with renal disorders, have two-fold longer period of in-hospital stay compared to the patients without renal dysfunction.3,27–29
Another large study analyzed the outcomes of ESRD patients who have undergone hepatic or pancreatic resections between 2005 and 2011.25 It was found that despite greater severity of postoperative course in the ESRD patients, liver and pancreatic resections are not excessively life-threatening in the selected ESRD patients: perioperative mortality rates were similar in ESRD and non-ESRD patients. On the other hand, ESRD patients subjected to pancreaticoduodenectomy developed major complications (respiratory disorders, sepsis) twice more frequently. It is likely that the lack of tolerance for long and complex surgery, due to the impaired physiological functions, contributes to the overall process.
At now, there is little information on how renal failure affects outcomes after pancreatic resection. For example, according to a single-center study, which encompassed 1061 patients with renal insufficiency, the postoperative outcomes after pancreatic resection were worse if a patient had the preoperative creatinine level of ≥1.8 mg/dL.30 This high-risk factor has also been associated to the significantly elevated risk of respiratory failure. In addition, the risk of post-surgical complications was found to be associated with CKD, if staged as severe (stage 4 or 5).30 It should be noted that the sample size may affect the statistical significance, as more patients who underwent Whipple procedures had serum creatinine levels ≥1.8 mg/dL, ie, 159.16 mmol/L (n = 19) compared with those classified as severe CKD (n = 9). Additionally, a higher proportion of patients with severe CKD had stage 5 CKD and therefore were already dialysis-dependent before surgery and continued scheduled hemodialysis after surgery. Authors also suggested that the fluid balance was better managed in severe CKD patients due to early planned hemodialysis after surgery. It may have contributed to a weaker association with complications or respiratory failure. In addition, the time between hemodialysis and surgery also affects postoperative complications. As shown by a retrospective cohort study,28 the patients received hemodialysis on the day of surgery had lower 90-day mortality. This study also showed that the interval between dialysis and surgery directly affects the risk of 90-day mortality. However, age was found to be a non-contributing factor to the postoperative morbidity in the patients with CKD subjected to pancreatic resection.31
Our patient had a number of factors that increased the risk of postoperative complications, including arterial hypertension, diabetes mellitus, and a creatinine level of 1171.30 μmol/L. In this case, adequate perioperative preparation and postoperative monitoring were critical. Surgery on the pancreas itself is associated with a high level of risks, and in patients on hemodialysis, these risks increase many times over. Therefore, patients with CKD stage IV–V are taken with great caution for extensive operations. For example, when searching for literature, no articles were found describing the performance of pancreaticoduodenal resection in patients on hemodialysis in Kazakhstan. However, examples from the world literature, as well as the example of our patient, demonstrate that with careful preparation of the patient this complex surgical treatment may be proposed with relatively low risk of post-operative mortality.
We should note limitations of our study. First, this is a single case in our clinic and therefore neither specific patient’s conditions nor post-operative outcomes can be interpreted from cohort-based point of view (generalization is limited). To attain needed level of interpretation for applicability and selection criteria for patients (based on risk assessment for individual patients), further studies or case series should be run or reported to validate the feasibility and safety of this approach in patients with severe renal disorders requiring permanent hemodialysis. Second, in our patient, we noted the negative progression in the form of metastatic-like spread of lesion. In this specific case, it is probable that the patient started to develop the metastatic progress (negative entity) prior to the surgery (positive entity), and the combined outcome superimposes these two entities. Considering the results of follow-up imaging of our patient, we can conclude that although the elective surgery can be performed safely in CKD and ESRD patients (assuming adequate pre-, intra-, and post-operative care), the progression of the cancer cannot be prevented without adjuvant chemotherapy. Again, more cases should be accumulated to evaluate the overall success rate of the surgery in these high-risk patients, including oncological patients.
Conclusions
To date and as far as we know, no clinical cases or papers describing the performance of pancreaticoduodenal resection in patients on hemodialysis in Kazakhstan are available. On the other hand, examples from the world literature, as well as this clinical case of our patient (being first reported in Kazakhstan), demonstrate that with careful pre-, peri-, and post-operative care of the patient, this operation is feasible and may both augment overall survival of patients and improve their life quality. The success of this surgical treatment in the specific patients requires multimodal personalized approach involving many specialists like surgeon, oncologist, anesthesiologist, nephrologist, internist, gastroenterologist, etc.
Data Sharing Statement
All data generated or analysed during this study are included in this published article.
Ethics Approval and Consent to Participate
This study itself as well as the institutional publication consent form for patients was approved by the local ethical board of the National Scientific Medical Center. All methods and treatments were performed accordingly to the relevant guidelines and regulations.
Consent for Publication
Written informed consent was obtained from the patient.
Acknowledgments
Authors would like to thank Dr Oleg Lookin for helping with preparation and editing of the manuscript.
Author Contributions
All authors significantly contributed to the study, including the conception development, study design, execution, data acquisition, data analysis/interpretation. They equally took part in the preparation of draft of the manuscript, revising or critically reviewing the manuscript. The authors confirm their final approval of the published version and the journal to which the paper has been submitted, and agree to be accountable for all aspects of the study.
Funding
No funding was received for this study.
Disclosure
The authors declare that they have no competing financial interests or personal relationships (known or putative) that could have appeared to influence the study reported in this manuscript.
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