No one anesthetic drug or drug combination is better for renal disease; most important is to maintain blood pressure and adequate renal perfusion. Diuresis of moderately or severely azotemic patients before anesthetic induction may be warranted. Base the specific fluid types and rates on patient condition and response, but generally 1.5–2 times maintenance crystalloid administration for the 12–24 hours before anesthesia will reduce the magnitude of the azotemia. Continue fluids into the postoperative period as patient needs dictate. Fluid rates up to 20–30 mL/kg/hr during anesthesia have been recommended in patients with renal dysfunction.10,11
Patients with renal insufficiency may benefit from mannitol-induced diuresis and the associated increased renal medullary perfusion.12,13To be effective, low-dose mannitol must be given before the ischemic episode; at higher doses it can cause renal vasoconstriction.
Vasopressors and inotropes have been recommended, but strictly to maintain cardiac output. It has not been concluded that they contribute to increased renal perfusion or renal protection.