Use of Sugammadex on Patients who have ESRD

This is a follow-up post on the Use of Sugammadex on Patient Who Has Myaesthenia Gravis.

Last week, I had a patient who has ESRD and on HD and patient was scheduled for a laparoscopic hernia repair case. Patient has active acid reflux and obese with BMI=40. We all know cisatricurium takes forever to take effect. Now that we have sugammadex to reverse rocuronium/vecuronium, rocuronium  can be a good alternative for patients who have renal insufficiency. Let’s review pharmacological facts of rocuronium. It is metabolized in the liver and excreted through bile and kidney. The duration of neuromuscular blockade may be prolonged and variable in patients with liver and kidney failure. Sugammadex binds to rocuronium/vecuronium and encapsulates the molecule. The 1:1 binding forms  cyclodextrin which reduces the amount of free NMB agent in plasma thereby reversing the neuromuscular blockade. The reversal of rocuronium by sugammadex depends on the encapsulation of rocuronium and not on the excretion of the sugammadex-rocuronium complex.  The complex is very stable and excreted by the kidney. 


Volume of distribution (Vd) of sugammadex is relatively small as it is water soluble and stays mainly in the central compartment. The half-life of sugammadex in patients with moderate, and severe renal impairment is 6, and 19 hours.  Sugammadex exposure is undoubtedly increased in patients with moderate and severe renal insufficiency as it is excreted by kidney.  De Souza et al reported that sugammadex 4 mg/kg was well tolerated in subjects with renal impairment.  This is supported by Min KC et al. that sugammadex can be successfully used to reverse patients with moderated and severe renal impairment. However, the recovery of the TOF ratio to 0.9 was prolonged in the renal failure group (5.6 ± 3.6 min) compared with the control group (2.7 ± 1.3 min, P = 0.003). For patient who are on HD, sugammadex and rocuronium were eliminated 69% and 75% in the plasma concentrations after the first dialysis session and about 50% respectively during the second dialysis sessions. 

Hence, we can see that sugammadex can be administered safely and effectively to patients who have renal impairment and received rocuronium/vecuronium muscle relaxlant.


 Min KC, Lasseter KCMarbury TCWrishko REHanley WDWolford DGUdo de Haes JReitmann CGutstein DEPharmacokinetics of sugammadex in subjects with moderate and severe renal impairment. Int J Clin Pharmacol Ther. 2017Sep;55(9):746-752. doi: 10.5414/CP203025.

De Souza CM1Tardelli MATedesco HGarcia NNCaparros MPAlvarez-Gomez JAde Oliveira Junior IS.fficacy and safety of sugammadex in the reversal of deep neuromuscular blockade induced by rocuronium in patients with end-stage renal disease: A comparative prospective clinical trial. Eur J Anaesthesiol. 2015 Oct;32(10):681-6. doi: 10.1097/EJA.0000000000000312. 

Dennis J. Cada, PharmD, FASHP, FASCP, (Editor),* Terri L. Levien, PharmD, and Danial E. Baker, Sugammadex. PharmD, FASHP, FASCPHosp Pharm. 2016 Jul; 51(7): 585–596.

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