Instructional Course Lecture
Renal and Gastrointestinal
Peter Pyrko, MD, PhD
Javad Parvizi, MD, FRCS
From the Rothman Institute, Thomas
Jefferson University, Philadelphia, PA.
This article, as well as other lectures
presented at the Academy’s Annual
Meeting, will be available in March
2016 in Instructional Course Lectures,
Volume 65.
Dr. Parvizi or an immediate family
member serves as a paid consultant
to CeramTec, ConvaTec, Medtronic,
Smith & Nephew, TissueGene, and
Zimmer; has stock or stock options
held in CD Diagnostics, Hip
Innovation Technology, and PRN; has
received research or institutional
support from 3M, Cempra, CeramTec,
DePuy, the National Institutes of
Health, the Orthopaedic Research
and Education Foundation, Smith &
Nephew, StelKast, Stryker, and
Zimmer; and serves as a board
member, owner, officer, or committee
member of the Eastern Orthopaedic
Association and the Muller
Foundation. Neither Dr. Pyrko nor any
immediate family member has
received anything of value from or has
stock or stock options held in a
commercial company or institution
related directly or indirectly to the
subject of this article.
J Am Acad Orthop Surg 2016;24:
e1-e8
http://dx.doi.org/10.5435/
JAAOS-D-14-00468
Copyright 2015 by the American
Academy of Orthopaedic Surgeons.
January 2016, Vol 24, No 1
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Considerations in Patients
Undergoing Elective Orthopaedic
Surgery
Abstract
To minimize perioperative complications after orthopaedic
procedures, patients may undergo medical optimization, which
includes an assessment of their renal function and gastrointestinal
(GI) system. The GI and renal systems are complex, and their proper
optimization in the preoperative period can influence the success of
any procedure. Several factors can prevent complications and reduce
morbidity, mortality, and the cost of care, including a thorough
evaluation and screening, with particular emphasis on anemia and its
renal and GI causes; management of medications that are
metabolized by the liver and excreted by the kidneys; and careful
attention to the patient’s nutritional status.
E lective orthopaedic surgery, such
as total joint arthroplasty, allevi-
ates pain and improves the quality of
renal and GI conditions share
numerous common complications,
including anemia, increased peri-
life for patients with end-stage arthri- operative blood loss as a result of
tis.1 The overall rate of complications platelet dysfunction, increased infec-
after orthopaedic procedures is low, tion rates,4,5 wound-related issues,6
and improvements in the quality of and the potential for fluid imbalance.
life equal or surpass those realized Other complications are specific to
after procedures such as coronary each organ system. It is important to
artery bypass graft or renal dialysis.2 note that some patients with severe
To reduce postoperative complica- renal and/or GI issues should not be
tions, patients typically are assessed subjected to elective orthopaedic
for the presence of various conditions procedures until these issues are ad-
that could compromise the outcomes dressed fully.
of elective procedures. Such assess- We believe that all patients under-
ment has been shown to reduce the going elective inpatient surgery—and
rate of perioperative complications those deemed at risk for renal or GI
during and after elective orthopaedic dysfunction who are undergoing
surgery.3 Patients are evaluated to more minor procedures—should be
identify modifiable risk factors that screened for anemia and renal dys-
can be controlled and optimized function. Elderly patients aged .80
before the elective procedure. Here, years should be screened for malnu-
we describe some of the important trition, as should those with a body
renal and gastrointestinal (GI) con- mass index (BMI) ,18.5 kg/m2 and
ditions that can be optimized before .35 kg/m2. Understandably, the
an elective procedure. Patients with additional laboratory evaluation adds
e1
Renal and Gastrointestinal Considerations in Patients Undergoing Elective Orthopaedic Surgery
Table 1
Common Laboratory Test Pricing at the Authors’ Institution
Test
Complete blood count with differential
Basic metabolic panel
PT/INR
PTT
Serum albumin
Prealbumin
Serum transferrin
PT/INR = prothrombin time/international normalized ratio, PTT = partial thromboplastin time
to cost. The pricing of common lab-
oratory tests at our institution is pre-
sented in Table 1.
Renal Considerations
Patients with renal conditions have
several issues that negatively affect
the outcomes of orthopaedic proce-
dures. Awareness of these issues may
enable optimization of these condi-
tions before elective procedures. Any
patient with a new diagnosis of renal
insufficiency or with known renal
dysfunction with a glomerular filtra-
tion rate (GFR) ,50 should undergo
further evaluation before undergoing
elective orthopaedic surgery. Table 2
lists common conditions found in
patients with renal disease.
Renal insufficiency is classified
based on the GFR: 60 to 89 is mild, 30
to 59 is moderate, 15 to 29 is severe,
and ,15 represents renal failure.
Any level of kidney disease increases
the surgical risks. We recommend
that any elevation of creatinine and
any reduction in GFR encountered
during preoperative laboratory
evaluation be followed with addi-
tional workup by a specialist.
Anemia
The presence of anemia negatively
affects the outcome of any surgical
procedure, including orthopaedic
procedures. In a recent study of
e2
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Price
$67
$381
$47
$76
$50
$184
$160
13,593 patients undergoing total joint
arthroplasty, Viola et al7 demon-
strated that patients with anemia had
a higher rate of complications than
did patients without anemia (odds
ratio, 2.11). The largest single com-
plication was cardiovascular and was
present in 26.5% of patients with
anemia compared with 11.8% of
those without anemia. Genitourinary
complications occurred in 3.9% of
anemic patients versus 0.9% in the
cohort without the condition. The
anemic patients had a fourfold increase
in the rate of infection, at 4.5%, versus
1.12% in the patients without anemia.
In addition, the length of the hospital
stay was substantially longer in the
group with anemia than in the group
without anemia.
Patients with anemia should be as-
sessed and their condition optimized
before undergoing elective orthopae-
dic procedures. The reason for the
increased complication rate in patients
with anemia may be multifactorial.
These patients are more likely to
require allogeneic blood transfusion,
with all its adverse consequences.8
Anemia as a result of renal disease is
the consequence of the underproduc-
tion of erythropoietin, the hormone
that stimulates erythrocyte pro-
duction.9 In a diseased kidney, the
underproduction of erythropoietin
ensues, and this process is directly
proportional to the residual kidney
function. Identifying and treating
Journal of the American Academy of Orthopaedic Surgeons
preoperative anemia can reduce mor-
tality and associated complications
such as infection.10,11 Thus, all
patients undergoing elective ortho-
paedic procedures should have a
complete blood count to detect ane-
mia. Patients with anemia should be
evaluated and treated. The adminis-
tration of hematinics, such as iron and
vitamins, or erythropoietin should be
considered, and all efforts should be
made to return the hemoglobin level
to normal before surgery.12
Vitamin D Metabolism
Human marrow stromal cells respond
to 1a, 25-dihydroxyvitamin D dur-
ing their conversion to osteoblasts
and actively participate in vitamin D
metabolism by converting 25-
dihydroxyvitamin D3 to 1a, 25
(OH)2D3. Chronic kidney disease
(CKD) is linked to the impaired
biosynthesis of 1a, 25(OH)2D.13
The absence of the active form of
vitamin D leads to hypocalcemia,
secondary hyperparathyroidism, hy-
pophosphatemia, and, as a result,
renal osteodystrophy. Patients with
renal osteodystrophy thus can pre-
sent with low bone quality as a result
of osteomalacia. Although not easily
correctable preoperatively, the low
quality of bone must be recognized
because it should prompt discussion
with the patient about the increased
risk of iatrogenic fractures and the
difficulty in achieving bony fixation.
Patients with osteomalacia may
require a modified surgical technique
and implant selection to minimize
the potential for complications.
Increasing numbers of orthopaedic
patients are at risk for vitamin D
deficiency. Thus, it may be reason-
able to check vitamin D levels in
patients undergoing complex ortho-
paedic procedures to ensure that
vitamin D deficiency, when present,
is corrected before surgery. These
patients have a higher risk of frac-
ture, impaired bone healing, and

diminished neuromuscular func-
tion.14 It is also crucial to continue
vitamin D and calcium repletion in
the postoperative period, based on
the established guidelines.
Edema and Acidosis
A decrease in water and acid clear-
ance leads to volume overload and
edema in patients with chronic renal
disease. Edema in the extremity pla-
ces these patients at risk of wound-
healing complications and should be
corrected preoperatively using the
appropriate diuretics and dialysis,
if possible.15 Edema and volume
overload also may lead to cardiac
and pulmonary complications. The
cardiac and pulmonary statuses need
to be monitored closely post-
operatively, and patients with renal
issues may require a monitored set-
ting in the immediate postoperative
period. Because metabolic acidosis
may be compounded by the insult of
surgery, it also should be corrected
preoperatively by an experienced
nephrologist.
Hyperkalemia
The accumulation of potassium occurs
in patients with chronic renal failure.
The homeostasis of potassium is
achieved by two mechanisms.16 In the
first, the kidneys are responsible for
excreting excess potassium. This is a
slow process that takes several hours.
In patients with renal failure, this
process is obtunded. In response, the
excretion of potassium by the gut is
increased, but this increase is insuffi-
cient to maintain homeostasis in the
presence of renal excretory insuffi-
ciency; hence, hyperkalemia ensues.
The second mechanism involves an
internal system that maintains potas-
sium balance through intracellular
shifts of potassium in response to
hormonal stimulus. This is a rapid
process that occurs in minutes. Of all
potassium in the body, 98% is found
intracellularly, whereas the remaining
January 2016, Vol 24, No 1
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Peter Pyrko, MD, PhD, and Javad Parvizi, MD, FRCS
Table 2
Common Conditions Affecting Patients With Renal Disease
Anemia resulting from reduced erythropoietin production
Deficiency of active Vitamin D, leading to hypocalcemia, secondary
hyperparathyroidism, hypophosphatemia, and renal osteodystrophy
Decreased acid and water secretion, leading to hypertension volume overload
and edema (acidosis compounded by surgery) and cardiac and pulmonary
overload
Hyperkalemia, leading to arrhythmia and other cardiac complications
Reduced renal clearance of some medications
Platelet dysfunction and increased risk of bleeding
Wound-related complications from delayed healing
Increased infection rates and mortality
Malnutrition from proteinuria or reduced production of albumin
Obtunded immunity caused by dysfunction of cell-mediated and humoral
immune system
2% is maintained in the extracellular substantial postoperative bleeding.18
space. This uneven distribution means Alternative anticoagulation must be
that small shifts from the intracellular used in patients with CKD. Contrast
space to the extracellular space can material is also nephrotoxic and
cause severe hyperkalemia, whereas should be avoided in patients with
small shifts into the cells can easily CKD.19 This fact may compel the
correct profound hyperkalemia. The physician to use imaging modalities
first process is the cause of the that do not rely on the administra-
increased serum potassium seen in tion of contrast material. Many of
CKD, and the second process is ex- the antibiotics given intraoperatively
ploited for rapid correction and and postoperatively are also neph-
treatment. The ultimate treatment of rotoxic and should be avoided.18
hyperkalemia in chronic renal failure Narcotic medications also can accu-
is dialysis and removal of potassium mulate in patients with CKD, so
from the blood stream. Maintaining doses should be adjusted and their
normal potassium levels is crucial effects monitored by an internist
because, left untreated, hyperkalemia to avoid respiratory depression.20
leads to cardiac complications, Common medications used in
including arrhythmias and cardiac orthopaedic surgery that require
arrest.17 renal dosing or avoidance are shown
in Table 3.
Renal Dosing of Medications
The kidneys metabolize and excrete Platelet Dysfunction and
several common medications used in Increased Risk of Bleeding
orthopaedic surgery, and the dosing Patients with renal disease in general
must be adjusted based on the creat- and those on dialysis in particular are
inine clearance. Several medications known to have platelet dysfunction.
need to be avoided in patients with The mechanism of this phenomenon
CKD. Avoidance of anticoagulants is typically linked to uremia or the
that are secreted by the kidney, such as damage of platelets during dialysis,
enoxaparin, is of paramount impor- or it may be secondary to the
tance because these drugs may accu- administration of anticoagulation
mulate in the bloodstream and cause medication during dialysis. The
e3
Renal and Gastrointestinal Considerations in Patients Undergoing Elective Orthopaedic Surgery

Table 3 patients with CKD are at increased

risk of complications and mortality.26
Common Medications Requiring Renal Dosing Before Orthopaedic
Surgery Another important fact to consider is
that patients on renal dialysis are
Medication Dosage
often carriers of methicillin-resistant
Enoxaparin Severe renal disease: Use different anticoagulant. For CrCl Staphylococcus aureus.28,29 There-
,30 mL/min, use 30 mg q 24 h. fore, antibiotic prophylaxis should be
Cefazolin CrCl 35–54 mL/min: Unchanged. adjusted for dialysis patients to
CrCl 11–34 mL/min: Give usual dose x 1, then decrease include methicillin-resistant S aureus
to 50%.
CrCl ,10 mL/min: Give usual dose x 1, then 50% q 18–24 h.
coverage.
The presence of impaired renal
Vancomycin CrCl 50–90 mL/min: Give 15 mg/kg x 1, then usual dose q
12–24 h. function also has been correlated with
CrCl 10–50 mL/min: Give 15 mg/kg x 1, then usual dose q an increased mortality rate.27,30-32
24–96 h. This correlation is not surprising
CrCl ,10 mL/min: Give 15 mg/kg x 1, then usual dose q 4–7 d. because cardiac and pulmonary
Morphine CrCl 10–50 mL/min: Decrease dose 25%. complications develop in patients
CrCl ,10 mL/min: Decrease dose 50%, monitor respiratory
status. with renal impairment and can be
fatal. The higher rate of infection in
CrCl = creatine clearance, q = every these patients also increases the risk
of mortality.

platelet count and the bleeding time
may need to be assessed in patients
with CKD before they undergo elec-
tive orthopaedic surgery, particularly
in those with a prior history of
excessive bleeding.21 Evidence shows
that a subpopulation of patients with
renal disease is resistant to the anti-
platelet action of aspirin.22
Wound-related
Complications From Delayed
Healing
The rate of wound complications is
increased in patients with CKD who
have edema, uremia, skin dryness, and
rashes. A high association of CKD
with diabetes mellitus as well as the
presence of peripheral vascular dis-
ease together with an increased sus-
ceptibility to infection also increases
the rate of wound complications in
patients with CKD.6,23 In addition,
patients on dialysis have been shown
to have dermal angiopathy, a mac-
rovascular disease leading to delayed
wound healing.24 Understanding this
phenomenon and discussing it with
the patient is essential to minimizing
wound complications in patients with
CKD and in those treated with
dialysis. Also critical are preoperative
optimization—focused on reducing
systemic edema—and careful surgical
technique with an emphasis on cau-
tious soft-tissue manipulation and
meticulous closure. The orthopaedic
procedure may need to be canceled if
these serious issues cannot be
addressed.
Increased Infection and
Mortality Rates
It is well established that patients
with CKD have an increased risk of
infection after elective orthopaedic
surgery.4,25-27 The direct cause of
this phenomenon is not well under-
stood but is likely multifactorial.
Patients with renal impairment have
more associated comorbidities, which
increase complications and mortality
because of the underlying pathology.
Patients on dialysis may be subject
to the entry of pathogens into the
bloodstream, which can result in a
subsequent infection. In addition,
some patients with CKD, especially
those who have had a renal transplant,
may be on immunosuppressive ther-
apy. Because of these mechanisms and
the direct effect of renal impairment,
Acute Kidney Injury After
Orthopaedic Surgery
Acute kidney injury (AKI) after
orthopaedic surgery is a serious
complication that leads to an increase
in mortality. Despite advances in
treatment, mortality in patients with
acute renal failure from all causes has
remained at approximately 50% in
the past 50 years.33 Identifying
patients at risk for AKI is critical in
the perioperative period to avoid this
potentially fatal complication. In one
study, the overall incidence of AKI
after elective or emergent orthopaedic
procedures was 8.9%.34 The risk
factors for AKI in the study were
dehydration, a history of diabetes
mellitus, preexisting kidney disease,
perioperative shock, and the admin-
istration of NSAIDs or nephrotoxic
antibiotics. The authors recom-
mended thorough preoperative eval-
uation and close postoperative
monitoring for patients with these
risk factors. Jafari et al35 evaluated
17,000 joint arthroplasty cases per-
formed during 7 years at their insti-
tution. The rate of AKI or acute renal
injury that they found was much
smaller than the 8.9% cited earlier, at

e4 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

0.55%. They identified a high BMI,
an elevated preoperative creatinine
level, chronic obstructive pulmonary
disease, congestive heart failure,
hypertension, and underlying cardiac
disease as risk factors for AKI or
acute renal injury. In their study,
renal impairment was correlated
closely with a longer hospital stay and
increased in-hospital mortality and 1-
year all-cause mortality. The authors
recommended perioperative optimi-
zation for patients with the risk fac-
tors they had established. In addition,
patients with kidney and liver trans-
plants have an increased risk of AKI
after hip arthroplasty, and solid
organ transplantation was found to
be an independent risk factor for
AKI.36
Gastrointestinal
Considerations
Patients undergoing orthopaedic
procedures may have underlying GI
conditions that can affect the out-
come of the surgical intervention.
Table 4 lists some of the common GI
conditions that may be present in
these patients.
Malnutrition
Malnutrition is a serious preop-
erative risk factor for any patient
undergoing elective orthopaedic sur-
gery regardless of BMI. Multiple
studies have demonstrated adverse
outcomes in malnourished patients
undergoing elective orthopaedic
surgery.37-39 A correlation exists
between malnutrition, poor wound
healing, and subsequent infection. In
one study, among patients with
drainage who did not respond to
irrigation and débridement, 35%
were found to be malnourished,
compared with 5% in the group
that responded to irrigation and
débridement.39 In an observational
study, Huang et al37 evaluated
.2,000 patients undergoing total
January 2016, Vol 24, No 1
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Peter Pyrko, MD, PhD, and Javad Parvizi, MD, FRCS
joint arthroplasty for the presence of
malnutrition. Of the patients in
the study, 8.5% were found to be
malnourished. The incidence of all
complications was substantially
higher in the malnourished patients
compared with that in patients
without malnutrition (12% versus
3.9%). The complications included
hematoma formation, infection, and
renal and cardiac events. Surpris-
ingly, obesity, defined by a BMI of
.30 kg/m2, was present in .40% of
malnourished patients, underscoring
the need for nutritional screening in
patients who are obese. In fact, some
authors define malnutrition not only
as the deficiency of nutrients but also
as an excess of nutrients, as is the
case in patients who are obese.38
Obesity in itself is associated with
multiple intraoperative and post-
operative complications, including
increased surgical times, persistent
wound drainage, and infection,
which may lead to local wound
complications.40
Malnutrition is rarely obvious
clinically and should be screened for
in at-risk populations, including
those older than 80 years and those
with a BMI .35 kg/m2. The most
common screening tests are the
serum total lymphocyte count, which
is positive for malnutrition if ,1,500
cells are present per cubic millimeter,
and the serum albumin concentra-
tion, which is positive for malnutri-
tion if the concentration is ,3.5
g/dL. Prealbumin and transferrin
tests also are used. Anthropomor-
phic measurements, including body
composition measurements such as
calf muscle circumference (,31 cm)
and arm muscle circumference (,22
mm), can indicate malnutrition.
These measurements better reflect
the patient’s long-term nutritional
status while underestimating acute
nutritional changes. Various nutri-
tional scoring tools also have been
proposed, such as the Mini Nutri-
tional Assessment.38
Table 4
Gastrointestinal Conditions
Affecting Elective Orthopaedic
Surgery
Malnutrition
Metabolic syndrome (eg, obesity,
hypertension, dyslipidemia, and
diabetes mellitus)
Chronic liver disease and cirrhosis
Alcohol consumption
Viral hepatitis
Dose adjustment of medications
metabolized by the liver
Inflammatory bowel disease
Ileus
Anemia resulting from poor nutrition
or acute gastrointestinal blood loss
Perioperative
Considerations in Patients
With Liver Disease
Many patients with liver disease are
asymptomatic; hence, the condition
may go undetected. Thus, vigilant
screening of patients through a care-
ful history and physical examination
is recommended to discover potential
risk factors for liver disease. In the
setting of newly discovered active
liver disease, it is recommended that
elective surgery be postponed until
the underlying cause of liver disease
can be determined, eliminated, or
treated. Cirrhosis of the liver leads to a
hyperdynamic circulation, with
increased cardiac output and decreased
peripheral vascular resistance. Pulmo-
nary hypertension, ascites, and bleed-
ing varices often are present. Because of
these issues, perioperative morbidity
and mortality are greatly increased in
patients with cirrhosis of the liver.41
Liver cirrhosis also is associated with
increased rates of periprosthetic joint
infections, prolonged hospital stay,
discharge to a nursing facility, read-
mission, urinary tract infection, renal
failure, blood transfusion, intestinal
hemorrhage, dislocation, and revision
surgery.42,43 Acute liver failure, active
viral hepatitis, alcoholic hepatitis,
e5
Renal and Gastrointestinal Considerations in Patients Undergoing Elective Orthopaedic Surgery
Table 5
Chronic Inflammatory Bowel Disease Medications and Recommended
Preoperative Cessation
Medication Half-Life
Methotrexate 0.7–5.8 h
Azathioprine 7.6 h
Infliximab 8–10 d
Adalimumab 12–14 d
Certolizumab 12–14 d
Glucocorticoids 12–48 h
OR = operating room
cardiomyopathy, hypoxemia, and
coagulopathy recalcitrant to treatment
are considered contraindications to
elective surgery.
In patients with liver disease, coag-
ulopathy is caused by the decreased
production of clotting factors second-
ary to reduced liver synthetic function
or depletion of vitamin K stores. Liver
disease also causes mild disseminated
intravascular coagulation, which may
lead to thrombocytopenia. Other
causes of thrombocytopenia include
the splenic sequestration of platelets
and alcohol-induced bone marrow
suppression.
To ensure improved outcomes of
orthopaedic procedures, the optimi-
zation of patients with liver disease is
warranted in collaboration with an
internist. A risk assessment of such
patients undergoing elective surgery
can be performed using established
risk-assessment tools such as the
Model for End-stage Liver Disease
and the Child-Pugh classification.
Alcohol Consumption
Excessive alcohol consumption (.40
units per week, which is equal to 400
gm of pure alcohol) is associated with
an increased risk of infectious and
noninfectious postoperative compli-
cations.44 Alcohol induces enzymatic
liver activity, which may lead to an
increased need for anesthetic agents
e6
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Recommended Discontinuation
Before Surgery
1 wk prior
Before 1 wk prior
3 wk prior
1 mo prior
1 mo prior
Administer stress dose in OR
and decreased efficacy of other med-
ications because of enhanced break-
down. At least 4 weeks of abstinence
has been suggested as being necessary
to reverse the pathophysiologic
changes that increase the risk of
postoperative morbidity and mortal-
ity in patients with excessive alcohol
consumption.45
Viral Hepatitis
As discussed earlier, acute viral hepa-
titis is a contraindication to elective
surgery. Chronic hepatitis is associ-
ated with an increased risk of peri-
operative complications.46,47 To our
knowledge, no official medical opti-
mization guidelines are available for
patients with chronic hepatitis. In one
study, patients with chronic hepatitis
C were found to be at higher risk of
infection and bleeding.48 In recent
years, immunotherapy has gained
attention for the treatment of patients
with hepatitis; some agents are pro-
posed to “cure” the condition. Thus,
it is important that a patient with
hepatitis be referred to a hepatologist
for possible treatment and medical
optimization prior to any elective
orthopaedic procedures.
Medication Dosing in Liver
Disease
Liver disease can lead to an increased
duration of action of certain drugs
Journal of the American Academy of Orthopaedic Surgeons
because of reduced liver metabolic
activity and lower than normal serum
levels of albumin. It also can lead to a
decrease in the duration of action
secondary to an increased volume of
distribution because of ascites. It is
important to follow each drug’s
dosing guidelines in patients with
liver disease to avoid overdosing. In
particular, care must be taken
to minimize the use of benzodiaze-
pines and opioids in patients with
liver disease.
Inflammatory Bowel Disease
Chronic inflammatory bowel disease
(CIBD), including Crohn disease and
ulcerative colitis, may pose a variety
of problems in the perioperative
period, including increased rates of
thromboembolic events.49 Anemia
is common in patients with CIBD
for a variety of reasons, including
the increased incidence of intestinal
bleeding, the reduced absorption of
hematinics and nutrients through
the small bowel, and the state of
chronic disease. Patients with
CIBD have been shown to be more
susceptible to infections and poor
wound healing.50 This fact may be
secondary to the autoimmune
nature of the disease or to the
administration of immunosuppres-
sive medications used for its treat-
ment. Many of the medications
used for the treatment of CIBD are
the same disease-modifying anti-
rheumatic drugs (DMARDs) used
in the management of inflamma-
tory arthropathies.51 Although the
optimal treatment of patients on
DMARDs is currently unknown,
the association between the
increased risk of infection and the
severity of infection, when it
occurs, led the attendees of the Inter-
national Consensus Meeting on
Periprosthetic Joint Infection to rec-
ommend that DMARDs be dis-
continued before elective arthroplasty52
(Table 5).

Ileus Prevention
Postoperative ileus, defined as the
cessation of bowel motility, is com-
mon after orthopaedic procedures,
particularly after spine surgery. Ileus
manifests with the delayed passage of
flatus and stool as well as increased
abdominal distention. Ileus likely
results from a sympathetic stress
response to surgery, the effect of
endogenous and administered opioids
on bowel movement, immobility,
prolonged recumbent positioning,
and bowel manipulation in trans-
abdominal spine surgery. Ileus also
may be associated with hypokalemia.
Postoperative ileus is linked to
reduced postoperative intake, pro-
longed hospital stays, patient dis-
comfort, increased pain, pulmonary
complications, delayed wound heal-
ing, and an increased cost of sur-
gery.53 Thus, the focus should be on
the prevention of ileus through the
early ambulation of patients when-
ever possible, the administration of
medications to increase GI mobility,
the minimization of opioid use for
pain control, and well-balanced
nutrition.
Anemia and Gastrointestinal
Bleeding
Anemia resulting from GI disorders is
of particular importance because it
often is correctable and has the
potential of making treatment of
other forms of anemia ineffective
when not corrected.53 In addition to
the causes described previously,
anemia can result from an insuffi-
cient absorption of iron or other
nutrients that are important in red
blood cell turnover and regenera-
tion. Malabsorption issues are cor-
rected easily by treating bowel
inflammation or with the supple-
mental administration of iron and
folic acid. In addition, it is important
to recognize iron deficiency anemia
in conjunction with other causes
of anemia because erythropoietin
January 2016, Vol 24, No 1
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Peter Pyrko, MD, PhD, and Javad Parvizi, MD, FRCS
treatment may be less effective in the
presence of an iron deficiency, and
coadministration of iron may be
required.54
GI bleeding is another common
cause of anemia, especially in elderly
patients. Screening for gastroesoph-
ageal reflux disease and inquiring
about its symptoms in patients with
anemia is important. The stress of
surgery can exacerbate the symptoms
of gastroesophageal reflux disease
and cause intestinal bleeding.
Appropriate preoperative treatment
and perioperative prophylaxis are
recommended. A stool guaiac test can
detect the presence of blood in the
stool. This test can be performed
easily for a patient with anemia dur-
ing preoperative clearance.
Summary
A thorough evaluation and screening
of patients—with the objective of
identifying and optimizing such
renal and GI conditions as anemia,
malnutrition, and alcohol abuse—
are vital to improve the outcomes of
elective orthopaedic procedures.
References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, references 10
and 54 are level I studies. Reference
45 is a level II study. References 11,
23, 33, and 38 are level III studies.
References 1, 3-9, 25-32, 34-37, 39-
44, and 46-48 are level IV studies.
References 2, 12-22, 24, and 49-53
are level V expert opinion.
References printed in bold type are
those published within the past 5
years.
1. Charnley J: The long-term results of low-
friction arthroplasty of the hip performed
as a primary intervention. 1972. Clin
Orthop Relat Res 1995;319:4-15.
2. Lavernia CJ, Guzman JF, Gachupin-
Garcia A: Cost effectiveness and quality of
life in knee arthroplasty. Clin Orthop Relat
Res 1997;345:134-139.
3. Radcliff KE, Orozco FR, Quinones D,
Rhoades D, Sidhu GS, Ong AC:
Preoperative risk stratification reduces the
incidence of perioperative complications
after total knee arthroplasty. J Arthroplasty
2012;27(8, suppl):77-80.
4. Poultsides LA, Ma Y, Della Valle AG,
Chiu YL, Sculco TP, Memtsoudis SG: In-
hospital surgical site infections after
primary hip and knee arthroplasty:
Incidence and risk factors. J Arthroplasty
2013;28(3):385-389.
5. Bozic KJ, Ong K, Lau E, et al: Estimating
risk in Medicare patients with THA: An
electronic risk calculator for periprosthetic
joint infection and mortality. Clin Orthop
Relat Res 2013;471(2):574-583.
6. Jones RE, Russell RD, Huo MH:
Wound healing in total joint replacement.
Bone Joint J 2013;95-B(11, suppl A):
144-147.
7. Viola J, Gomez MM, Restrepo C,
Maltenfort MG, Parvizi J: Preoperative
anemia increases postoperative
complications and mortality following total
joint arthroplasty. J Arthroplasty 2015;30
(5):846-848.
8. Augustin ID, Yeoh TY, Sprung J, Berry DJ,
Schroeder DR, Weingarten TN:
Association between chronic kidney disease
and blood transfusions for knee and hip
arthroplasty surgery. J Arthroplasty 2013;
28(6):928-931.
9. McClellan W, Aronoff SL, Bolton WK,
et al: The prevalence of anemia in patients
with chronic kidney disease. Curr Med Res
Opin 2004;20(9):1501-1510.
10. Eschbach JW, Egrie JC, Downing MR,
Browne JK, Adamson JW: Correction of the
anemia of end-stage renal disease with
recombinant human erythropoietin: Results
of a combined phase I and II clinical trial.
N Engl J Med 1987;316(2):73-78.
11. Rosencher N, Poisson D, Albi A,
Aperce M, Barré J, Samama CM: Two
injections of erythropoietin correct
moderate anemia in most patients
awaiting orthopedic surgery. Can J
Anaesth 2005;52(2):160-165.
12. Goodnough LT, Maniatis A, Earnshaw P,
et al: Detection, evaluation, and
management of preoperative anaemia in the
elective orthopaedic surgical patient:
NATA guidelines. Br J Anaesth 2011;106
(1):13-22.
13. Zhou S, Leboff MS, Waikar SS, Glowacki J:
Vitamin D metabolism and action in human
marrow stromal cells: Effects of chronic
kidney disease. J Steroid Biochem Mol Biol
2013;136:342-344.
14. Patton CM, Powell AP, Patel AA: Vitamin
D in orthopaedics. J Am Acad Orthop Surg
2012;20(3):123-129.
e7
Renal and Gastrointestinal Considerations in Patients Undergoing Elective Orthopaedic Surgery
15. Carrasco LR, Chou JC: Perioperative
management of patients with renal disease.
Oral Maxillofac Surg Clin North Am 2006;
18(2):203-212, vi.
16. Allon M: Hyperkalemia in end-stage renal
disease: Mechanisms and management.
J Am Soc Nephrol 1995;6(4):1134-1142.
17. Shingarev R, Allon M: A physiologic-based
approach to the treatment of acute
hyperkalemia. Am J Kidney Dis 2010;56
(3):578-584.
18. Hartmann B, Czock D, Keller F: Drug
therapy in patients with chronic renal
failure. Dtsch Arztebl Int 2010;107(37):
647-655, quiz 655-656.
19. Rudnick MR, Berns JS, Cohen RM,
Goldfarb S: Contrast media-associated
nephrotoxicity. Semin Nephrol 1997;17(1):
15-26.
20. Kurella M, Bennett WM, Chertow GM:
Analgesia in patients with ESRD: A review
of available evidence. Am J Kidney Dis
2003;42(2):217-228.
21. Dorgalaleh A, Mahmudi M, Tabibian S,
et al: Anemia and thrombocytopenia in acute
and chronic renal failure. Int J Hematol
Oncol Stem Cell Res 2013;7(4):34-39.
22. Kilickesmez KO, Kocas C, Abaci O,
Okcun B, Gorcin B, Gurmen T: Follow-up
of aspirin-resistant patients with end-stage
kidney disease. Int Urol Nephrol 2013;45
(4):1097-1102.
23. Seth AK, De la Garza M, Fang RC,
Hong SJ, Galiano RD: Excisional wound
healing is delayed in a murine model of
chronic kidney disease. PLoS One 2013;8
(3):e59979.
24. Lundin AP, Fani K, Berlyne GM,
Friedman EA: Dermal angiopathy in
hemodialysis patients: The effect of time.
Kidney Int 1995;47(6):1775-1780.
25. Deegan BF, Richard RD, Bowen TR,
Perkins RM, Graham JH, Foltzer MA:
Impact of chronic kidney disease stage on
lower-extremity arthroplasty. Orthopedics
2014;37(7):e613-e618.
26. McCleery MA, Leach WJ, Norwood T:
Rates of infection and revision in patients
with renal disease undergoing total knee
replacement in Scotland. J Bone Joint Surg
Br 2010;92(11):1535-1539.
27. Miric A, Inacio MC, Namba RS: Can total
knee arthroplasty be safely performed in
patients with chronic renal disease? Acta
Orthop 2014;85(1):71-78.
28. Schmid H, Romanos A, Schiffl H,
Lederer SR: Persistent nasal methicillin-
resistant staphylococcus aureus carriage in
hemodialysis outpatients: A predictor of
worse outcome. BMC Nephrol 2013;14:93.
29. Otter JA, French GL: Nosocomial
transmission of community-associated
e8
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
methicillin-resistant Staphylococcus aureus:
An emerging threat. Lancet Infect Dis
2006;6(12):753-755.
30. Miric A, Inacio MC, Namba RS: The effect
of chronic kidney disease on total hip
arthroplasty. J Arthroplasty 2014;29(6):
1225-1230.
31. Aynardi M, Jacovides CL, Huang R,
Mortazavi SM, Parvizi J: Risk factors for
early mortality following modern total hip
arthroplasty. J Arthroplasty 2013;28(3):
517-520.
32. Bozic KJ, Lau E, Kurtz S, et al: Patient-
related risk factors for periprosthetic joint
infection and postoperative mortality
following total hip arthroplasty in
Medicare patients. J Bone Joint Surg Am
2012;94(9):794-800.
33. Ympa YP, Sakr Y, Reinhart K, Vincent JL:
Has mortality from acute renal failure
decreased? A systematic review of the
literature. Am J Med 2005;118(8):827-832.
34. Kateros K, Doulgerakis C, Galanakos SP,
Sakellariou VI, Papadakis SA,
Macheras GA: Analysis of kidney
dysfunction in orthopaedic patients. BMC
Nephrol 2012;13:101.
35. Jafari SM, Huang R, Joshi A, Parvizi J,
Hozack WJ: Renal impairment following
total joint arthroplasty: Who is at risk?
J Arthroplasty 2010;25(6, suppl):49-53.
36. Choi YJ, Lee EH, Hahm KD, Kwon K,
Ro YJ: Transplantation is a risk factor for
acute kidney injury in patients undergoing
total hip replacement arthroplasty for
avascular necrosis: An observational study.
Transplant Proc 2013;45(6):2220-2225.
37. Huang R, Greenky M, Kerr GJ, Austin MS,
Parvizi J: The effect of malnutrition on
patients undergoing elective joint
arthroplasty. J Arthroplasty 2013;28(8,
suppl):21-24.
38. Cross MB, Yi PH, Thomas CF, Garcia J,
Della Valle CJ: Evaluation of malnutrition
in orthopaedic surgery. J Am Acad Orthop
Surg 2014;22(3):193-199.
39. Jaberi FM, Parvizi J, Haytmanek CT,
Joshi A, Purtill J: Procrastination of
wound drainage and malnutrition affect
the outcome of joint arthroplasty. Clin
Orthop Relat Res 2008;466(6):
1368-1371.
40. Liabaud B, Patrick DA Jr, Geller JA: Higher
body mass index leads to longer operative
time in total knee arthroplasty.
J Arthroplasty 2013;28(4):563-565.
41. Bhangui P, Laurent A, Amathieu R,
Azoulay D: Assessment of risk for non-
hepatic surgery in cirrhotic patients.
J Hepatol 2012;57(4):874-884.
42. Tiberi JV III, Hansen V, El-Abbadi N,
Bedair H: Increased complication rates
Journal of the American Academy of Orthopaedic Surgeons
after hip and knee arthroplasty in patients
with cirrhosis of the liver. Clin Orthop
Relat Res 2014;472(9):2774-2778.
43. Jiang SL, Schairer WW, Bozic KJ: Increased
rates of periprosthetic joint infection in
patients with cirrhosis undergoing total
joint arthroplasty. Clin Orthop Relat Res
2014;472(8):2483-2491.
44. Bradley KA, Rubinsky AD, Sun H, et al:
Alcohol screening and risk of
postoperative complications in male VA
patients undergoing major non-cardiac
surgery. J Gen Intern Med 2011;26(2):
162-169.
45. Tonnesen H, Rosenberg J, Nielsen HJ, et al:
Effect of preoperative abstinence on poor
postoperative outcome in alcohol misusers:
Randomised controlled trial. BMJ 1999;
318(7194):1311-1316.
46. Orozco F, Post ZD, Baxi O, Miller A,
Ong A: Fibrosis in hepatitis C patients
predicts complications after elective total
joint arthroplasty. J Arthroplasty 2014;29
(1):7-10.
47. Best MJ, Buller LT, Klika AK,
Barsoum WK: Increase in perioperative
complications following primary total hip
and knee arthroplasty in patients with
hepatitis C without cirrhosis. J Arthroplasty
2015;30(4):663-668.
48. Pour AE, Matar WY, Jafari SM, Purtill JJ,
Austin MS, Parvizi J: Total joint arthroplasty
in patients with hepatitis C. J Bone Joint Surg
Am 2011;93(15):1448-1454.
49. Kumar A, Auron M, Aneja A, Mohr F,
Jain A, Shen B: Inflammatory bowel
disease: Perioperative pharmacological
considerations. Mayo Clin Proc 2011;86
(8):748-757.
50. Sholter DE, Armstrong PW: Adverse
effects of corticosteroids on the
cardiovascular system. Can J Cardiol
2000;16(4):505-511.
51. Scanzello CR, Figgie MP, Nestor BJ,
Goodman SM: Perioperative management
of medications used in the treatment of
rheumatoid arthritis. HSS J 2006;2(2):
141-147.
52. Parvizi J, Gehrke T, Chen AF: Proceedings
of the International Consensus on
Periprosthetic Joint Infection. Bone Joint J
2013;95-B(11):1450-1452.
53. Thompson M, Magnuson B: Management
of postoperative ileus. Orthopedics 2012;
35(3):213-217.
54. Auerbach M, Ballard H, Trout JR, et al:
Intravenous iron optimizes the response to
recombinant human erythropoietin in
cancer patients with chemotherapy-related
anemia: A multicenter, open-label,
randomized trial. J Clin Oncol 2004;22(7):
1301-1307.