Anesthesia and Surgery in the Patient with Renal Failure

  • David R. Bevan


Most patients with chronic renal failure (CRF) will receive anesthesia for vascular access before hemodialysis, for renal transplantation, or for surgery unrelated to their renal disease. CRF is associated with systemic disease, which increases the problems of anesthesia. The purpose of this chapter is to review the major obstacles to safe anesthesia, to describe the changes induced by renal failure, in the activity of drugs used during anesthesia, and to recommend safe approaches to anesthesia in CRF. Most patients are now well controlled by dialysis and, before renal transplantation, will usually have received hemodialysis within 48 hours of the procedure, so severe cardiovascular and biochemical disturbances are seldom observed at the time of surgery.


Renal Transplantation Chronic Renal Failure Tracheal Intubation Mean Residence Time Atrial Natriuretic Factor 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Bastron RD, Bailey G, Deutsch S, Vandam LD: Anesthesia for patients with chronic renal failure for renal homo-transplantation. Anesthesiology 30: 335–336, 1969.CrossRefGoogle Scholar
  2. 2.
    Samuel JR, Powell D: Renal transplantation. Anaesthetic experience of 100 cases. Anaesthesia 25: 165–176, 1970.PubMedCrossRefGoogle Scholar
  3. 3.
    Monks PS, Lumley J: Anaesthetic aspects of renal transplantation. Ann R Coll Surg Engl 50: 354–366, 1972.PubMedGoogle Scholar
  4. 4.
    Logan DA, Howie HB, Crawford J: Anaesthesia for renal transplantation: an analysis of fifty-six cases. Br J Anaesth 46: 69–72, 1974.PubMedCrossRefGoogle Scholar
  5. 5.
    Uldall PR, Wilkinson R, Dewar PJ, et al.: Factors affecting the outcome of cadaver renal transplantation in Newcastle upon Tyne. Lancet 2: 316–319, 1977.PubMedCrossRefGoogle Scholar
  6. 6.
    Jindal HH, Hirsch DJ, Belitsky P, Whalen MA: Low-dose subcutaneous erythropoietin corrects the anaemia of renal transplant faailure. Nephrol Dial Transplant 7: 143–146, 1992.PubMedGoogle Scholar
  7. 7.
    Haljamae H, Rosenberg PH: Present and future concepts in transfusion practice. Acta Anaesthesiol Scand 32 (Suppl 89): 13, 1988.Google Scholar
  8. 8.
    Gillies IDS: Anaemia and anaesthesia. Br J Anaesth 46: 589602, 1974.Google Scholar
  9. 9.
    Prys-Roberts C: Anaesthesia and hypertension. Br J Anaesth 56: 711–724, 1984.CrossRefGoogle Scholar
  10. 10.
    Miller DR, Martineau RJ, Wynands JE: Bolus administration of esmolol for controlling the haemodynamic response to tracheal intubation: the Canadian multicentre trial. Can J Anaesth 38: 849–858, 1991.PubMedCrossRefGoogle Scholar
  11. 11.
    Singh PP, Dimich I, Sampson I, Sonnenklar N: A comparison of esmolol and labetalol for the treatment of perioperative hypertension in geriatric ambulatory surgical patients. Can J Anaesth 39: 559–562, 1992.PubMedCrossRefGoogle Scholar
  12. 12.
    Goldman L, Caldera DL: Risks of general anesthesia and elective operation in the hypertensive patient. Anesthesiology 50: 285–292, 1979.PubMedCrossRefGoogle Scholar
  13. 13.
    Cronnelly R, Kremer PF, Beaupre P, Cahalan MK, Salvatierra O, Feduska N: Hemodynamic response to fluid challenge in anesthetized patients with end-stage renal disease. Anesthesiology 59: A49, 1983.Google Scholar
  14. 14.
    Carlier M, Squifflet J-P, Pirson Y, Gribomont B, Alexandre GPJ: Maximal hydration during anesthesia increases pulmonary artery pressures and improves early function of human renal transplants. Transplantation 34: 201–204, 1982.PubMedCrossRefGoogle Scholar
  15. 15.
    Tasker PRW, MacGregor GA, de Wardener HE: Prophylactic use of intravenous saline in patients with chronic renal failure undergoing major surgery. Lancet 2: 911–912, 1974.PubMedCrossRefGoogle Scholar
  16. 16.
    Eiser AR: Pulmonary gas exchange during hemodialysis and peritoneal dialysis: interaction between respiration and metabolism. Am J Kidney Dis 6: 131–142, 1985.PubMedGoogle Scholar
  17. 17.
    Goggin MJ, Joekes AM: Gas exchange in renal failure. I. Dangers of hyperkalaemia during anaesthesia. Br Med J 2: 244–147, 1971.PubMedCrossRefGoogle Scholar
  18. 18.
    Koide M, Waud BE: Serum potassium concentrations after succinylcholine in patients with renal failure. Anesthesiology 36: 142–144, 1972.PubMedCrossRefGoogle Scholar
  19. 19.
    Soulillou JP, Fillaudeau F, Keribin JP, Guenel J: Acute hyperkalemia risks in recipients of kidney graft cooled with Collins’ solution. Nephron 19: 301–304, 1977.PubMedCrossRefGoogle Scholar
  20. 20.
    McNamee PT, Moore GW, McGeown MG, Doherty CC, Collins BJ: Gastric emptying in chronic renal failure. Br Med J 291: 310–11, 1985.CrossRefGoogle Scholar
  21. 21.
    Symreng T, Karlberg BR, Kagedal B, Schildt B: Physiological cortisol substitution of long-term steroid-treated patients undergoing major surgery. Br J Anaesth 53: 949–954, 1981.PubMedCrossRefGoogle Scholar
  22. 22.
    Sokoll MD, Gergis SD: Antibiotics and neuromuscular function. Anesthesiology 55: 148–159, 1981.PubMedCrossRefGoogle Scholar
  23. 23.
    Chauvin M, Sandouk P, Scherrmann JM, Farinotti, Strumza P, Duvaldestin P: Morphine pharmacokinetics in renal failure. Anesthesiology 66: 327–331, 1987.PubMedCrossRefGoogle Scholar
  24. 24.
    Guidelines to the practice of anaesthesia as recommended by the Canadian Anaesthetists’ Society. Can J Anaesth 41 (Suppl 3): 1–16, 1994.Google Scholar
  25. 25.
    Ghonheim MM, Pandya H: Plasma protein binding of thiopental in patients with impaired renal or hepatic function. Anesthesiology 42: 545–549, 1975.CrossRefGoogle Scholar
  26. 26.
    Richet G, de Novales EL, Verroust P: Drug intoxication and neurological episodes in chronic renal failure. Br Med J 2: 394395, 1970.Google Scholar
  27. 27.
    Freeman RB, Sheff MF, Maher JF, Schreiner GE: The blood cerebrospinal fluid barrier in uremia. Ann Intern Med 56:233240.Google Scholar
  28. 28.
    Hobika GH, Evers JL, Mostert JW, Trudnowski RJ, Moore RH, Murphy GP: Comparison of hemodynamic effects of glucagon and ketamine in patients with chronic renal failure. Anesthesiology 37: 654–658, 1972.PubMedCrossRefGoogle Scholar
  29. 29.
    Holaday DA, Fiserova-Bergerova V, Latto IP, Zumbiel MA: Resistance of isoflurane to biotransformation in man. Anesthesiology 43: 325–332.Google Scholar
  30. 30.
    Eger EI II: Recovery from anesthesia. In: Eger EI II, ed, Anesthetic Uptake and Action. Baltimore: Williams & Wilkins, p. 228, 1974.Google Scholar
  31. 31.
    Osborne RJ, Joel SP, Slevin ML: Morphine intoxication in renal failure: the role of morphine-6-glucuronide. Br Med J 292: 1548–1549, 1986.CrossRefGoogle Scholar
  32. 32.
    Szeto, HH, Inturrisi CE, Houde R, Saal S, Cheigh J, Redenberg MM: Accumulation of normeperidine, an active metabolite of meperidine, in patients with renal failure or cancer. Ann Intern Med 86: 738–741, 1977.PubMedCrossRefGoogle Scholar
  33. 33.
    Chauvin M, Lebrault C, Levron JC, Duvaldestin P: Pharmacokinetics of alfentanil in chronic renal failure. Anesth Analg 66: 53–56, 1987.PubMedCrossRefGoogle Scholar
  34. 34.
    Sear JW: Sufentanil disposition in patients undergoing renal transplantation: influence of choice of kinetic model. Br J Anaesth 63: 60–67, 1989.PubMedCrossRefGoogle Scholar
  35. 35.
    Martyn JAJ, White DA, Gronert GA, Jaffe RS, Ward JM: Up-and-down regulation of skeletal muscle acetylcholine receptors. Anesthesiology 76: 822–843, 1992.PubMedCrossRefGoogle Scholar
  36. 36.
    Holmes JH, Makamoto S, Sawyer KC: Changes in blood composition before and after dialysis with the Kolff twin coil kidney. Trans Am Soc Artific Intern Organs 4: 16–18, 1958.Google Scholar
  37. 37.
    Ryan DW: Postoperative serum cholinesterase activity following successful renal transplantation. Br J Anaesth 51: 881–884, 1979.PubMedCrossRefGoogle Scholar
  38. 38.
    Dretchen KL, Morgenroth VH, Standaert FG, Waits LF: Azathioprine: effects on neuromuscular transmission. Anesthesiology 45: 604–609, 1976.PubMedCrossRefGoogle Scholar
  39. 39.
    Fahey MR, Morris RB, Miller RD, Nguyen T-L, Upton RA: Pharmacokinetics of ORG NC45 (Norcuron) in patients with and without renal failure. Br J Anaesth 55: 6–11, 1981.CrossRefGoogle Scholar
  40. 40.
    Stenlake JB, Waugh RD, Dewar GH, Hughes R, Chapple DJ, Coker GG: Biodegradable neuromuscular blocking agents. Part 4. Atracurium besylate and related polyalkylene di-esters. Eur J Med Chem 16: 515–524, 1981.Google Scholar
  41. 41.
    Nigrovic V, Pandya JB, Auen M, Wajskol A: Inactivation of atracurium in human and rat plasma. Anesth Analg 64: 1047–1052, 1985.PubMedCrossRefGoogle Scholar
  42. 42.
    Cook DR, Freeman JA, Lai AA, et al.: Pharmacokinetics of mivacurium in normal patients and in those with hepatic or renal failure. Br J Anaesth 69: 580–585, 1992.PubMedCrossRefGoogle Scholar
  43. 43.
    Szenohradszky J, Fisher DM, Segredo V, et al.: Pharmacokinetic of rocuronium bromide (ORG 9426) in patients with normal renal function or patients undergoing renal transplantation. Anesthesiology 77: 899–904, 1992.PubMedCrossRefGoogle Scholar
  44. 44.
    Phillips BJ, Hunter JM: Use of mivacurium chloride by constant infusion in the anephric patient. Br J Anaesth 68: 492–498, 1992.PubMedCrossRefGoogle Scholar
  45. 45.
    Hunter JM, Jones RS, Utting JE: Use of atracurium in patients with no renal function. Br J Anaesth 54: 1251–1258, 1982.PubMedCrossRefGoogle Scholar
  46. 46.
    Cronnelly R, Stanski DR, Miller RD, Sheiner LB, Soh YJ: Renal function and the pharmacokinetics of neostigmine in anesthetized man. Anesthesiology 51: 222–226, 1979.PubMedCrossRefGoogle Scholar
  47. 47.
    Morris RB, Cronnelly R, Miller RD, Stanski DR, Fahey MR: Pharmacokinetics of edrophonium in anephric and renal transplant patients. Br J Anaesth 53: 1311–1314, 1981.PubMedCrossRefGoogle Scholar
  48. 48.
    Rennick BR: Renal tubule transport of organic cations. Am J Physiol 9: F83 - F89, 1981.Google Scholar
  49. 49.
    Bevan DR, Donati F, Kopman A: Reversal of neuromuscular blockade. Anesthesiology 77: 785–805.Google Scholar
  50. 50.
    Bevan DR, Archer DP, Donati F, Ferguson A, Higgs BD: Reversal of pancuronium in renal failure: no recurarization. Br J Anaesth 54: 63–68, 1982.PubMedCrossRefGoogle Scholar
  51. 51.
    Mouquet C, Bitker MO, Bailliart O, et al.: Anesthesia for creation of a forearm fistula in patients with endstage renal failure. Anesthesiology 70: 909–914, 1989.PubMedCrossRefGoogle Scholar
  52. 52.
    Bromage PR, Gertel M: Brachial plexus block in chronic renal failure. Anesthesiology 36:488–493, ••.Google Scholar
  53. 53.
    Beauregard L, Martin R, Tetrault J-P: Brachial plexus block and chronic renal failure. Can J Anaesth 34: 5118, 1987.Google Scholar
  54. 54.
    Wyant GM: The anaesthetist looks at tissue transplantation: three years experience with kidney transplantation. Can Anaesth Soc J 14: 225–234, 1967.CrossRefGoogle Scholar
  55. 55.
    Lofstrom B: Anaesthetic problems in renal transplantation. J Urol Nephrol 1: 161–169, 1967.CrossRefGoogle Scholar
  56. 56.
    Shanks CA: Pharmacokinetics of the non-depolarizing neuromuscular relaxants applied to calculation of bolus and infusion dose regimens. Anesthesiology 64: 72–86, 1986.PubMedCrossRefGoogle Scholar
  57. 57.
    Levinsky NG, Bernard DB: Mannitol and loop diuretics in acute renal failure. In: JM Brenner, JM Lazarus, eds, Acute Renal Failure, 2nd ed. Churchill Livingstone, New York, pp 841–856, 1988.Google Scholar
  58. 58.
    Myles PS, Buckland MR, Schenk NJ, et al.: Effect of “renal-dose” dopamine on renal function following cardiac surgery. Anaesth Intensive Care 21: 56–61, 1993.PubMedGoogle Scholar
  59. 59.
    Luciani J, Franz P, Thibault P, Ghesquiere F, Conseiller C, Cousin M-T, Glaser P, LeGrain M, Viars P, Kuss R: Early anuria prevention in human kidney transplantation. Advantages of fluid loading under pulmonary artery pressure monitoring during the surgical period. Transplantation 28: 308–312, 1979.PubMedCrossRefGoogle Scholar
  60. 60.
    Lieberthal W, Sheridan AM, Valeri CR: Protective effect of atrial natriuretic factor and mannitol following renal ischemia. Am J Physiol 258: F1266 - F1272, 1990.PubMedGoogle Scholar
  61. 61.
    Power I, Cumming AD, Pugh GC: Effect of diclofenac on renal function and prostacyclin after surgery. Br J Anaesth 69: 451–456, 1992.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 1998

Authors and Affiliations

  • David R. Bevan
    • 1
  1. 1.Department of AnaesthesiaUniversity of British Columbia, Vancouver General HospitalVancouverCanada

Personalised recommendations