Anaesthesia in chronic dialysis patients: A narrative review

Table 1 Pharmacologic considerations for common anaesthesia agents in chronic dialysis patients

Drug	Dose change in renal Impairment	Dialysable	Comments
Sedatives
Propofol	-	No	Metabolized by the liver. No dose adjustment is necessary for any degree of renal impairment[4-7]. Because metabolites theoretically accumulate with longer infusions, vigilance is advised
Ketamine	-	No	Metabolized by the liver. No dose adjustment is necessary for any degree of renal impairment
Thiopentone	↓	No	Predominantly undergoes hepatic metabolism with urinary excretion of metabolites. Dose must be reduced by 25%-30%[8]. Clearance via haemodialysis is negligible[9]
Etomidate	-	Unknown	Rapid metabolism in the liver and plasma. No dose adjustment is necessary
Midazolam	↓	No	Predominantly undergoes hepatic metabolism with urinary excretion of metabolites. Boluses can be administered without any dose adjustment[10]. Continuous infusions require lowered doses. Metabolites accumulate with extended use, resulting in a prolonged half-life and sedative effect[11-13]. However, the effect is inconsistent with significant interpersonal variability
Volatile Gases	-	Unknown	Primarily eliminated via exhalation (e.g. halothane, desflurane, sevoflurane); renal excretion is minor. No dose adjustment is necessary for any degree of renal impairment[6,14,15]
Analgesics
Morphine	↓	Yes	Metabolized through hepatic glucuronidation with urinary elimination of metabolites. Morphine metabolites accumulate with renal dysfunction, resulting in a prolonged half-life. A 75% reduction is recommended for both bolus and infusion doses[16-18]. No opioids are dialysable in subjects with preserved kidney function because intrinsic clearance exceeds the rate of removal via dialysis. Morphine is considered dialysable in those with advanced kidney impairment; however, extracorporeal removal is rarely indicated in practice due to the success of supportive care and naloxone as an antidote[3]
Oxycodone	↓	Yes	Undergoes hepatic glucuronidation. Metabolites accumulate with renal impairment. Dose should be reduced by 25%-50%
Fentanyl	-	No	Hepatic metabolism followed by mainly urinary clearance. Because of its short half-life, accumulation occurs only with continuous use. No dose adjustments are required for bolus dosing[19]. Continuous infusion doses should be reduced by approximately 25-50%[17,20]
Remifentanil	-	No	Rapidly metabolized by blood and tissue enzymes, with metabolites excreted in the urine. No dose adjustment is necessary
Paralytics
Suxamethonium	-	Unknown	Suxamethonium is hydrolyzed rapidly and undergoes minimal urinary excretion. No dose adjustments are required. Be aware of the risk of hyperkalaemia
Rocuronium	-	Unknown	Undergoes hepatic metabolism followed by biliary and renal excretion. No dose adjustments are typically recommended in patients with renal impairment; however, this interaction is poorly understood. In some experimental studies of patients with renal failure, clearance was reduced by a third and half-life was extended by up to 50%. Therefore, rocuronium is best avoided where prolonged paralysis is undesirable[21-23]. Sugammadex reversal is contraindicated due to insufficient safety data in chronic dialysis patients
Cisatracurium	-	Unknown	No dose adjustment is necessary. Although the half-life is nominally increased in kidney failure, cisatracurium is rapidly metabolized via Hofmann degradation
Regional Anaesthetics
Lidocaine	-	No	No dose adjustments for kidney function are required when used for local or regional anaesthesia. Spinal and epidural regional anaesthesia, such as with ropivicaine or bupivacaine, appears safe in chronic dialysis patients[24,25]