For health providers guiding the end-stage renal disease patient's care, conventional surgical and anesthetic principles may demand substantial modifications to optimize both the immediate outcome and long-term survival. Elective operation is conducted in the setting of optimized acid/base balance, volume status and potassium management with pre-operative dialysis completed within 24 hours of the procedure (either hemodialysis or peritoneal dialysis). When peripheral intravenous access is inadequate, central venous access is obtained preferentially through the internal jugular veins because of the catastrophic consequences of catheter-induced subclavian stenosis. Infectious prophylaxis incorporates antibiotic selection considering the lack of native renal drug clearance, the potential for drug loss across dialysis membranes and potential interactions with immunosuppressive medications. Judicious intraoperative blood and fluid replacement should not be so restricted as to permit inadequate end organ perfusion, even if post-operative dialysis is necessitated. Hemostasis may be facilitated by the use of desmopressin to correct uremic platelet dysfunction. Wound closure techniques should accommodate the delayed healing associated with kidney failure and/or iatrogenic immunosuppression.