Those patients with end stage renal failure who are maintained on peritoneal dialysis should continue dialysing until they go to theatre. Haemodialysis should be ideally undertaken with minimum heparinisation up to 12 hours prior to elective surgery. The excretion of water soluble drugs and their active metabolites will be impaired. For drugs which are renally excreted the half life increases slowly with deteriorating renal function until severe nephron loss at which point the half life increases sharply with further reductions in renal function. Dialysis can only usually replace a small part of the excretory capacity of the healthy kidney.
Induction agents Their effect is terminated by redistribution.
All of these agents are myocardial depressants and should be administered cautiously in patients with heart disease. Muscle relaxants Suxamethonium should be avoided if hyperkalaemia is present. Some non-depolarising muscle relaxants depend on the kidney for elimination. Atracurium is the agent of choice as it undergoes spontaneous Hoffman degradation at body temperature. Vecuronium and mivacurium are safe to use in renal failure as only small percentages are excreted renally.