Efficacy and Safety of Sugammadex for the Reversal of Rocuronium-Induced Neuromuscular Blockade in Patients with End-Stage Renal Disease: A Systematic Review and Meta-Analysis

Abstract

Background and Objectives: Sugammadex is widely used in anesthesia to reverse rocuronium-induced neuromuscular blockade (NMB). In patients with compromised kidney function, most drugs show alteration of their pharmacokinetic profile with reduced clearance. The purpose of this article is to examine the efficacy, pharmacokinetics, and safety of sugammadex in end-stage renal disease (ESRD) patients receiving general anesthesia, using a systematic review. Materials and Methods: The databases of PubMed, EMBASE, the Cochrane Library, Web of Science, Scopus, KoreaMed, and ClinicalTrials.gov were searched for studies comparing the efficacy or safety outcomes of sugammadex administration for the reversal of rocuronium-induced NMB, in ESRD patients (group R) or in those with normal renal function (group N) undergoing surgery under general anesthesia. Results: We identified nine studies with 655 patients—six prospective, case-control studies with 179 patients (89 and 90 in groups R and N) and three retrospective observational studies with 476 ESRD patients. In the six prospective studies, the times taken to reach a train-of-four ratio ≥0.9, 0.8, and 0.7 were significantly longer in group R than in group N (weighted mean difference [95% confidence interval] [min]: 1.14 [0.29 to 2.00], 0.9 [0.24 to 1.57], 0.89 [0.20 to 1.57], respectively). The total plasma clearance of sugammadex was significantly lower in group R than in group N. There was no significant difference in the incidence of NMB recurrence and prolonged time to recovery between the groups. In the three retrospective studies, the possibility of sugammadex-related adverse events appears to be insignificant. Conclusions: Sugammadex may effectively and safely reverse rocuronium-induced NMB in patients with ESRD, although the recovery to a TOF ratio of 0.9 may be prolonged compared to patients with normal renal function. Further studies are needed, considering the small number of studies included and the high heterogeneity of some of the results.

Response to "A novel use of neostigmine reversal for intraoperative neural monitoring during thyroid surgery"

“…A recent systematic review article with a meta-analysis showed that sugammadex may effectively and safely reverse rocuronium-induced neuromuscular blockade in patients with end-stage renal disease. 5 We read the comments by the authors on our study with interest and we agree that further investigation is necessary.…”

Sugammadex administration in patients with end-stage renal disease: a narrative review with recommendations

“…A recently published systematic review found that the time required to reach a TOF ratio ≥ 0.9, 0.8, or 0.7 was significantly longer in patients with ESRD. The plasma clearance of sugammadex in patients with ESRD was significantly lower than that in healthy controls, based on meta-analysis of six prospective observational studies [ 4 ]. However, given that the difference in the recovery time is not long enough to cause a clinically significant difference (e.g., the mean difference of the time to reach a TOF ratio of 0.9:1.14 min), it is believed that the NMB reversal time in patients with ESRD is slightly longer than that in patients with normal renal function.…”

“…Total plasma clearance of sugammadex in patients with ESRD was significantly lower than that in healthy controls [ 7 , 10 ]. Total plasma clearance of rocuronium in patients with ESRD was significantly lower than that in healthy controls [ 4 ]. Additionally, the effect of renal impairment on total plasma clearance was found to be greater with sugammadex than with rocuronium [ 7 ].…”

“…Several prospective case-control studies, retrospective cohort studies, and case reports on the administration of sugammadex in patients with ESRD (or patients undergoing kidney transplantation) have been reported. A systematic review and meta-analysis [ 4 ], presented data analysis results on its efficacy and safety by synthesizing and integrating the results of studies reporting the use of sugammadex, and a retrospective study that investigated relatively long-term mortality [ 5 ], were reported. Table 1 shows the characteristics and results of the relevant studies.…”

Choice of neuromuscular block reversal agent to reduce postoperative pulmonary complications

“…None of them were due to the recurrence of NMB. Although some studies have investigated the efficacy and safety of sugammadex use in ESRD patients [ 61 , 62 ], evidence regarding the effect on PPCs in ESRD patients is insufficient, and more data and research are required.…”