Gastrointestinal Cancer Surgery in Patients on Maintenance Hemodialysis: A Prisma Guided Systematic Review and Propensity Score Matched Cohort Analysis
Ali Abdelhady, Yara Sakr, Rayner P. Cardoso, Eman Zineldin, Courtney Scaife, Marshall Baker, Erin Ward, T. Clark GamblinABSTRACT
Background
Patients receiving maintenance hemodialysis (HD) have limited physiologic reserve and high competing cardiometabolic risk, yet surgery remains central to cure for many gastrointestinal (GI) malignancies. Evidence describing oncologic surgery in this population is fragmented across cancer sites and data sources.
Methods
A PRISMA guided systematic review of adult patients on maintenance HD undergoing resection for GI malignancy was performed. The review searched PubMed, Embase, Web of Science, and CENTRAL through March 2026 and included comparative observational studies reporting perioperative or long‐term outcomes. In parallel, a propensity‐score matched TriNetX cohort of adults undergoing major GI cancer surgery between 2010 and 2025. HD was defined by preoperative ESRD and dialysis dependence codes. Patients were matched 1:1 on age, sex, race, and ethnicity. The primary outcome was 30‐day mortality; secondary outcomes were 30‐day sepsis, pneumonia, and acute myocardial infarction (AMI).
Results
The review included 20 studies after screening 1,744 deduplicated records and 83 full texts. Colorectal surgery provided the most robust evidence: dialysis was associated with markedly higher mortality and serious morbidity, and a published meta‐analysis of colorectal surgery estimated a pooled mortality odds ratio (OR) of 4.12. Gastric, pancreatic, and hepatobiliary reports were smaller but showed the same direction of effect, with frequent infectious and cardiovascular complications and substantial competing non‐cancer mortality. In the current TriNetX analysis, 3,757 HD patients were matched to 3757 non‐HD controls. Thirty‐day mortality was 11.4% in HD patients versus 3.0% in controls (OR: 4.21, 95% CI: 3.40–5.22). HD patients also had higher rates of sepsis (14.1% vs. 3.9%; OR 4.06), pneumonia (8.1% vs. 2.2%; OR: 4.02), and AMI (4.3% vs. 0.9%; OR: 5.18).
Conclusions
Across GI cancer operations, maintenance HD identifies a very high‐risk surgical phenotype. The dominant short‐term pattern is excess death, infection, and cardiopulmonary morbidity; the dominant long‐term pattern is competing non‐cancer mortality. Surgery remains appropriate for selected patients with resectable disease, but perioperative dialysis timing, multidisciplinary optimization, and treatment in experienced centers are critical.