Section 20
Renal diseases

Alert

  • A substantial proportion of patients undergoing dialysis may be unfit to drive or may have episodes when they are temporarily unfit to drive (especially after dialysis treatments).
  • Screening questionnaires are available that may help to identify patients who are at risk for being unfit to drive and who might benefit from more detailed evaluation. However, evidence is insufficient to mandate the routine use of these questionnaires in clinical practice.
  • Dialysis patients who are concerned about their ability to drive should be encouraged to speak to a physician and avoid driving until their concern has been addressed.
  • Medical and paramedical personnel should consider seat-belt pressure points when implanting invasive medical devices (e.g., central venous catheters or peritoneal dialysis catheters).

20.1 Overview

This section reviews issues associated with dialysis and renal transplantation. Patients with end-stage renal disease may be treated with facility-based or home hemodialysis or with home peritoneal dialysis. Most patients can continue to drive safely after adjusting to a stable dialysis regimen.

Patients on dialysis often experience concurrent medical problems or general debility that can lead to a temporary or permanent inability to drive safely. The attending physician should counsel the patient appropriately if any problems arise that could make driving hazardous, including a potentially short-term but serious change in health status, such as a systemic infection, significant electrolyte abnormality, ischemic coronary event, or symptoms such as weakness or hypotension that occur while adjusting to a new dialysis regimen.

20.2 Dialysis

Patients with end-stage renal disease maintained on hemodialysis or peritoneal dialysis can drive any class of motor vehicle, provided they possess adequate cognitive and sensorimotor ability.

Drivers considering long-distance trips must take into account their access to dialysis treatments and supplies.

All commercial drivers must be under the supervision of a nephrologist or an internist and must undergo an annual medical review. Commercial drivers must be able to receive appropriate dialysis therapy while performing their work. For patients undergoing peritoneal dialysis, adequate supplies and an appropriate physical environment for exchanges must always be available. Hemodialysis is generally not a feasible treatment modality for a long-distance driver. If a commercial driver is planning to travel significant distances from home, unexpected delays due to weather, highway conditions, or demands of their work must be considered to ensure that dialysis treatments are not missed.

20.2.1 Hemodialysis

Patients undergoing facility-based hemodialysis may have multiple cardiovascular and diabetic comorbidities. In assessing their fitness to drive, physicians should evaluate these patients individually for the presence of relevant comorbidities, medications, and adverse symptoms associated with their treatments.

Few studies provide clinicians with validated tools to identify dialysis patients who may not be fit to drive. A study of 186 patients receiving dialysis in the United States (89% hemodialysis, 11% peritoneal dialysis) revealed that 40% of surveyed patients were “not comfortable driving” (Vats and Duffy, 2010). However, 42% of this group continued to drive, with 48% of those reporting crashes. Approximately three-quarters of patients who admitted to feeling uncomfortable driving reported one or more symptoms of weakness, dizziness, or difficulty with coordination after a hemodialysis session.

Varela et al. (2015) analyzed the accuracy of an instrument developed by the American Automobile Association and the American Medical Association to assess the safety of geriatric drivers, as applied specifically to 106 dialysis patients (68% hemodialysis, 32% peritoneal dialysis). The “Am I a Safe Driver?” checklist asks patients to answer 24 specific questions (one of which was omitted for the dialysis patients). The authors concluded that answering “yes” to two or more questions on the checklist was potentially useful for identifying patients at high risk for driving impairment (84% sensitivity, 58% specificity), but confirmation by other methods was required, as nearly half of “screen-positive” patients might still be considered safe to drive.

These studies suggest that (1) a substantial proportion of patients receiving dialysis (especially hemodialysis) may have episodes when they are not fit to drive, especially after dialysis sessions; and (2) a checklist such as “Drivers 65 Plus: Check Your Performance” (AAA Foundation for Traffic Safety, 2019) may be useful for identifying patients who require further evaluation. However, the data are insufficient to mandate regular screening of dialysis patients with this instrument or available alternatives.

Dialysis staff may consider asking patients how they plan to return home in the event of a highly symptomatic hemodialysis session and discussing alternative arrangements for patients who had planned to drive but do not appear well enough to do so.

Hemodialysis patients should not drive further than one or two days’ distance from their home without making arrangements for dialysis at another centre. If a longer road trip is planned, such patients should consult with their local dialysis unit, which will have access to lists of dialysis centres in Canada and the United States that will accept travelling patients. The patient’s overall health and stability on dialysis should be evaluated by their attending nephrologist before any travel plans are made.

20.2.2 Peritoneal dialysis

The fitness-to-drive issues for patients undergoing peritoneal dialysis are similar to those for hemodialysis patients, as outlined in Section 20.2.1, Hemodialysis. However, peritoneal dialysis is associated with slower, more continuous fluid removal, and thus symptoms relating to intravascular fluid shifts and hemodynamics are less of a problem than with hemodialysis.

20.3 Renal transplant

Drivers who have had a successful renal transplant and who have fully recovered from the surgery can drive a motor vehicle.

References

AAA Foundation for Traffic Safety. Drivers 65 plus: check your performance. A self-rating tool with facts and suggestions for safe driving. In: Pomidor A, editor. Clinician’s guide to assessing and counseling older drivers. 4th ed. New York (NY): American Geriatrics Society; 2019. p. 188-99. Available: https://www.safemobilityfl.com/pdfs/CliniciansGuide/CliniciansGuideOlde…

Vats HS, Duffy DP. Assessment of self-perceived risk and driving safety in chronic dialysis patients. Dial Transplant. 2010;39(2):63-8.

Varela D, Mallawaarachchi I, Blandon P. A diagnostic screening tool for identifying safe drivers among dialysis patients. Clin Nephrol. 2015;83(1):22-8.