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Multicenter Study
. 2025 Jun 1;142(6):1009-1024.
doi: 10.1097/ALN.0000000000005411. Epub 2025 Feb 10.

Neuromuscular Blockade and Antagonism in Patients with Renal Impairment: A Multicenter Retrospective Cross-sectional Study

Rania Elkhateb  1 , Davis L Campbell  2 , Xinyi Zhao  3 , Graciela Mentz  3 , Nadir El Sharawi  1 , Sathish Kumar  3 , Jill M Mhyre  1 , Sachin Kheterpal  3 , Douglas A Colquhoun  3 ; Multicenter Perioperative Outcomes Group Perioperative Clinical Research Committee
Collaborators, Affiliations
Multicenter Study

Neuromuscular Blockade and Antagonism in Patients with Renal Impairment: A Multicenter Retrospective Cross-sectional Study

Rania Elkhateb et al. Anesthesiology. .

Abstract

Background: Current practice guidelines do not address the use of neuromuscular blocking and antagonism agents in patients with renal impairment. The U.S. Food and Drug Administration (Silver Spring, Maryland) label for sugammadex advises against use in patients with severe renal impairment (estimated glomerular filtration rate [eGFR] less than 30 ml/min). Using a multicenter electronic health record registry, the authors sought to understand the modern use of neuromuscular blockade and antagonism agents in patients with significant renal impairment (eGFR less than 60 ml/min).

Methods: Data were obtained from the Multicenter Perioperative Outcomes Group (MPOG) registry for adult patients (older than 18 yr) with an eGFR less than 60 ml/min, based on most recent serum creatinine, receiving general anesthesia for a nonrenal transplant procedure with an endotracheal tube between January 1, 2016, and July 31, 2022. Patients were classified into three mutually exclusive blockade and reversal strategies: rocuronium-sugammadex, cisatracurium-neostigmine, and rocuronium-neostigmine. Adjusted incidence of each blockade reversal strategy was established by a multinomial mixed effects model. The contribution of institution, anesthesiologist, and patient or case factors to variation in strategy choice was assessed by multilevel mixed effects models.

Results: In 243,944 cases across 5,133 anesthesiologists and 48 institutions, adjusted use of rocuronium-sugammadex increased from 4.4 to 95.2%, rocuronium-neostigmine decreased from 84.7 to 4.3%, and cisatracurium-neostigmine decreased from 10.9 to 0.5%. In patients with an eGFR less than 15 ml/min, rocuronium-sugammadex use increased from 0.5 to 86.9%. Of the variation in choice of rocuronium-sugammadex versus cisatracurium-neostigmine, 30.1% was attributed to the institution, 22.7% to the attending anesthesiologist, and 47.2% to patient/case factors or was unexplained. The adjusted median odds ratio for this choice was 2.5 for clinicians and 3.1 for institutions.

Conclusion: Rocuronium-sugammadex is the primary neuromuscular blockade-antagonism strategy for patients with moderate and severe renal impairment. Variation in choice is significantly impacted by the institution and attending anesthesiologist providing care.

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Conflict of interest statement

Drs Colquhoun, Mentz, Kheterpal declare past research support from Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., (Rahway, New Jersey) paid to the University of Michigan unrelated to presented work.

Dr Kumar declares research support paid to the University of Michigan, unrelated to present work from Hemosonics, LLC (Durham, North Carolina) and Edwards Lifesciences (Irvine, California).

Dr Mhyre declares editorial compensation for International Anesthesia Research Society (San Francisco, California), American Board of Anesthesiology (Raleigh, North Carolina), UpToDate (Waltham, Massachusetts), and Elsevier (New York, New York), and a stipend for service on the Board of Directors for the Arkansas Foundation for Medical Care (Little Rock, Arkansas). All of these are unrelated to the presented work.

Dr Colquhoun reports research support paid to the University of Michigan, unrelated to the presented work from Chiesi, USA (Cary, North Carolina) and GE Healthcare (Chicago, IL).

Dr Colquhoun reports receiving an honorarium from Medscape, Inc (New York, New York).

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