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Renal failure

Created: 9/11/2004
The aetiology of renal failure is important, plus associated medical conditions

Effect on drug handling

  • Protein-bound drugs have increased free fractions due to acidosis and hypoalbuminaemia
  • Lipid-insoluble drugs are excreted renally
  • The kidney excretes hepatic metabolites of lipid-soluble drugs
  • Uraemia may change the structure and function of drugs

Fluids and electrolytes

  • Hypervolaemia
  • Oedema
  • Hypertension
  • Metabolic acidosis
  • Hyperkalaemia (may rise with suxamethonium, catabolic stress, acidosis, potassium-sparing diuretics)
  • Hypermagnesaemia (inadequate dialysis)
  • Hypocalcaemia : 2o/3o hyperparathroidism and leading to bone resorption, osteoporosis, osteomalacia and fractures

Medical conditions with uraemia

  • Hypertension
  • Pericarditis and effusion
  • Atherosclerosis and ischaemic heart disease
  • Pulmonary oedema
  • Atelectasis, pneumonia and adult respiratory distress syndrome
  • Depressed immunity
  • Poor wound healing
  • Peptic ulceration with elevated gastrin - increased risk of aspiration


  • Normochromic, normocytic
  • 2o to decreased erythropoietin secretion
  • Multiple transfusions increase risk of acquired infection
  • Uraemic coagulopathy


  • Physical status and timing of last dialysis
  • Vascular access sites should be noted with reference to any shunts
  • Optimal time 24 hours post-haemodialysis but peritoneal dialysis can be carried on until surgery
  • Transfusion during dialysis preferably
  • Urea and electrolytes: correct hypertension and hyperkalaemia
  • Clotting correction


  • Consider regional anaesthesia
  • Avoid lactate-containing solutions
  • Patient positioning - re: shunt sites
  • Watch fluid status/central venous pressure monitoring
  • IV lines away from shunts
  • Measure urine output
  • Rapid sequence induction due to increased risk of aspiration
  • Pre-oxygenation due to anaemia


  • Suxamethonium may have a prolonged effect and may induce arrhythmias
  • Avoid hypotension with induction agents
  • Atracurium/vecuronium agents of choice
  • Avoid enflurane, as toxic metabolite formed
  • Treat hypotension with fluid
  • Dopamine may increase renal perfusion


  • Watch for fluid overload
  • Dehydration
  • Residual neuromuscular blockade
  • Watch urea and electrolytes
  • Analgesia with regional or carefully titrated opioids

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