Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Anesthesia for the patient on dialysis

Jeremy P Campbell, MB, ChB (Hons.), MRCS, FRCA
Jonathan M Cousins, BSc, MBBS, FRCA, FFICM
Section Editors
Michael Avidan, MD
Stephanie B Jones, MD
Jeffrey S Berns, MD
Deputy Editors
Nancy A Nussmeier, MD, FAHA
Alice M Sheridan, MD


End-stage renal disease (ESRD) is a growing problem worldwide [1] (see "Epidemiology of chronic kidney disease"). In the United States, >90 and <10 percent of patients with ESRD are receiving hemodialysis and peritoneal dialysis, respectively. Dialysis-dependent patients may require surgery for a predictable variety of reasons, including vascular access procedures, parathyroidectomy, and renal transplantation. Patients may also require elective or emergent surgical procedures for reasons that are unrelated to their ESRD.

This topic reviews the preanesthesia consultation and the anesthetic and immediate postoperative management of dialysis patients. Preoperative medical management of these patients is discussed in detail elsewhere (see "Medical management of the dialysis patient undergoing surgery"). Anesthetic management of dialysis-dependent patients undergoing renal transplantation is discussed separately. (See "Preanesthesia consultation for renal transplant recipients".)


General considerations — Hemodialysis and peritoneal dialysis are renal replacement therapies that are used to remove metabolic waste products and excess volume (sodium and water) from circulation and to correct certain acid–base and electrolyte abnormalities. Patients on maintenance hemodialysis will generally have received dialysis 24 to 48 hours prior to elective surgery. Hemodialysis patients undergoing nonelective surgery may have received dialysis up to 72 hours prior to presentation. Patients on peritoneal dialysis generally have daily dialysis that may be continued until just prior to surgery. (See "Medical management of the dialysis patient undergoing surgery", section on 'Routine dialysis prior to surgery'.)

Preoperative anesthetic assessment includes determination of the following details:

Type of dialysis (hemodialysis, peritoneal dialysis)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Oct 2017. | This topic last updated: Jan 07, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. United States Renal Data System. 2014 Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institutes of Health; National Institute of Diabetes and Digestive and Kidney Diseases, MD 2014.
  2. Ahmed J, Weisberg LS. Hyperkalemia in dialysis patients. Semin Dial 2001; 14:348.
  3. Esposito C, Bellotti N, Fasoli G, et al. Hyperkalemia-induced ECG abnormalities in patients with reduced renal function. Clin Nephrol 2004; 62:465.
  4. Aslam S, Friedman EA, Ifudu O. Electrocardiography is unreliable in detecting potentially lethal hyperkalaemia in haemodialysis patients. Nephrol Dial Transplant 2002; 17:1639.
  5. Weisberg LS. The risk of preoperative hyperkalemia. Semin Dial 2003; 16:78.
  6. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2215.
  7. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 2014; 64:e77.
  8. Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 2014; 35:2383.
  9. Trainor D, Borthwick E, Ferguson A. Perioperative management of the hemodialysis patient. Semin Dial 2011; 24:314.
  10. Higashi M, Yamaura K, Ikeda M, et al. Diastolic dysfunction of the left ventricle is associated with pulmonary edema after renal transplantation. Acta Anaesthesiol Scand 2013; 57:1154.
  11. Kawar B, Ellam T, Jackson C, Kiely DG. Pulmonary hypertension in renal disease: epidemiology, potential mechanisms and implications. Am J Nephrol 2013; 37:281.
  12. Yigla M, Nakhoul F, Sabag A, et al. Pulmonary hypertension in patients with end-stage renal disease. Chest 2003; 123:1577.
  13. Sandham JD, Hull RD, Brant RF, et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 2003; 348:5.
  14. Barone JE, Tucker JB, Rassias D, Corvo PR. Routine perioperative pulmonary artery catheterization has no effect on rate of complications in vascular surgery: a meta-analysis. Am Surg 2001; 67:674.
  15. Polanczyk CA, Rohde LE, Goldman L, et al. Right heart catheterization and cardiac complications in patients undergoing noncardiac surgery: an observational study. JAMA 2001; 286:309.
  16. Rajaram SS, Desai NK, Kalra A, et al. Pulmonary artery catheters for adult patients in intensive care. Cochrane Database Syst Rev 2013; :CD003408.
  17. Zimmerman D, Sood MM, Rigatto C, et al. Systematic review and meta-analysis of incidence, prevalence and outcomes of atrial fibrillation in patients on dialysis. Nephrol Dial Transplant 2012; 27:3816.
  18. Lenihan CR, Montez-Rath ME, Scandling JD, et al. Outcomes after kidney transplantation of patients previously diagnosed with atrial fibrillation. Am J Transplant 2013; 13:1566.
  19. KDOQI. KDOQI Clinical Practice Guideline and Clinical Practice Recommendations for anemia in chronic kidney disease: 2007 update of hemoglobin target. Am J Kidney Dis 2007; 50:471.
  20. Song HK, von Heymann C, Jespersen CM, et al. Safe application of a restrictive transfusion protocol in moderate-risk patients undergoing cardiac operations. Ann Thorac Surg 2014; 97:1630.
  21. Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice guideline from the AABB*. Ann Intern Med 2012; 157:49.
  22. Carson JL, Carless PA, Hebert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev 2012; :CD002042.
  23. Spiegel DM, Khan I, Krishnan M, Mayne TJ. Changes in hemoglobin level distribution in US dialysis patients from June 2006 to November 2008. Am J Kidney Dis 2010; 55:113.
  24. Leffell MS, Kim D, Vega RM, et al. Red blood cell transfusions and the risk of allosensitization in patients awaiting primary kidney transplantation. Transplantation 2014; 97:525.
  25. Jalal DI, Chonchol M, Targher G. Disorders of hemostasis associated with chronic kidney disease. Semin Thromb Hemost 2010; 36:34.
  26. Pivalizza EG, Abramson DC, Harvey A. Perioperative hypercoagulability in uremic patients: a viscoelastic study. J Clin Anesth 1997; 9:442.
  27. Devereaux PJ, Mrkobrada M, Sessler DI, et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med 2014; 370:1494.
  28. Lindsay RM, Friesen M, Aronstam A, et al. Improvement of platelet function by increased frequency of hemodialysis. Clin Nephrol 1978; 10:67.
  29. Lee HK, Kim YJ, Jeong JU, et al. Desmopressin improves platelet dysfunction measured by in vitro closure time in uremic patients. Nephron Clin Pract 2010; 114:c248.
  30. American Society of Anesthesiologists Task Force on Perioperative Blood Management. Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management*. Anesthesiology 2015; 122:241.
  31. Strid H, Simrén M, Stotzer PO, et al. Delay in gastric emptying in patients with chronic renal failure. Scand J Gastroenterol 2004; 39:516.
  32. Salles Junior LD, Santos PR, dos Santos AA, de Souza MH. Dyspepsia and gastric emptying in end-stage renal disease patients on hemodialysis. BMC Nephrol 2013; 14:275.
  33. American Society of Anesthesiologists Committee. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology 2011; 114:495.
  34. Driessen JJ, Vree TB, Guelen PJ. The effects of acute changes in renal function on the pharmacokinetics of midazolam during long-term infusion in ICU patients. Acta Anaesthesiol Belg 1991; 42:149.
  35. Spina SP, Ensom MH. Clinical pharmacokinetic monitoring of midazolam in critically ill patients. Pharmacotherapy 2007; 27:389.
  36. Calvo R, Suárez E, Rodríguez-Sasiain JM, Martínez I. The influence of renal failure on the kinetics of intravenous midazolam: an "in vitro" and "in vivo" study. Res Commun Chem Pathol Pharmacol 1992; 78:311.
  37. Vinik HR, Reves JG, Greenblatt DJ, et al. The pharmacokinetics of midazolam in chronic renal failure patients. Anesthesiology 1983; 59:390.
  38. Troianos CA, Jobes DR, Ellison N. Ultrasound-guided cannulation of the internal jugular vein. A prospective, randomized study. Anesth Analg 1991; 72:823.
  39. American Society of Anesthesiologists Task Force on Central Venous Access, Rupp SM, Apfelbaum JL, et al. Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology 2012; 116:539.
  40. Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 2003; 327:361.
  41. Rang ST, West NL, Howard J, Cousins J. Anaesthesia for chronic renal disease and renal transplantation. EAU-EBU Update Series 2006; 4:246. http://eu-acme.org/europeanurology/upload_articles/PIIS1871259206000505.pdf (Accessed on November 17, 2020).
  42. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med 2010; 35:64.
  43. Gogarten W, Van Aken H, Büttner J, et al. Regional anaesthesia and thromboembolism prophylaxis/anticoagulation: Revised recommendations of the German Society of Anaesthesiology and Intensive Care Medicine. Anasthesiol Intensivmed Notfallmed Schmerzther 2007; 48:S109. www.google.com/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=2&cad=rja&uact=8&ved=0CCUQFjAB&url=http%3A%2F%2Fwww.ak-regionalanaesthesie.dgai.de%2Fempfehlungen-links%2Fempfehlungen%2Fdoc_download%2F63-rueckenmarksnahe-regionalanaesthesien-und-thrombo-embolieprophylaxeantithrombotische-medikatio (Accessed on November 15, 2014).
  44. Working Party:, Association of Anaesthetists of Great Britain & Ireland, Obstetric Anaesthetists' Association, Regional Anaesthesia UK. Regional anaesthesia and patients with abnormalities of coagulation: the Association of Anaesthetists of Great Britain & Ireland The Obstetric Anaesthetists' Association Regional Anaesthesia UK. Anaesthesia 2013; 68:966.
  45. Dhir S, Fuller J. Case report: pregnancy in hemodialysis-dependent end-stage renal disease: anesthetic considerations. Can J Anaesth 2007; 54:556.
  46. Shemesh D, Olsha O, Orkin D, et al. Sympathectomy-like effects of brachial plexus block in arteriovenous access surgery. Ultrasound Med Biol 2006; 32:817.
  47. Gulyam Kuruba SM, Mukhtar K, Singh SK. A randomised controlled trial of ultrasound-guided transversus abdominis plane block for renal transplantation. Anaesthesia 2014; 69:1222.
  48. Kirvelä M, Olkkola KT, Rosenberg PH, et al. Pharmacokinetics of propofol and haemodynamic changes during induction of anaesthesia in uraemic patients. Br J Anaesth 1992; 68:178.
  49. Ickx B, Cockshott ID, Barvais L, et al. Propofol infusion for induction and maintenance of anaesthesia in patients with end-stage renal disease. Br J Anaesth 1998; 81:854.
  50. Bovill JG. Intravenous anesthesia for the patient with left ventricular dysfunction. Semin Cardiothorac Vasc Anesth 2006; 10:43.
  51. Shafer SL. The pharmacology of anesthetic drugs in elderly patients. Anesthesiol Clin North America 2000; 18:1.
  52. Shafer SL. Shock values. Anesthesiology 2004; 101:567.
  53. Thapa S, Brull SJ. Succinylcholine-induced hyperkalemia in patients with renal failure: an old question revisited. Anesth Analg 2000; 91:237.
  54. Ryan DW. Preoperative serum cholinesterase concentration in chronic renal failure. Clinical experience of suxamethonium in 81 patients undergoing renal transplant. Br J Anaesth 1977; 49:945.
  55. Fahey MR, Rupp SM, Fisher DM, et al. The pharmacokinetics and pharmacodynamics of atracurium in patients with and without renal failure. Anesthesiology 1984; 61:699.
  56. Bryson HM, Faulds D. Cisatracurium besilate. A review of its pharmacology and clinical potential in anaesthetic practice. Drugs 1997; 53:848.
  57. Sparr HJ, Beaufort TM, Fuchs-Buder T. Newer neuromuscular blocking agents: how do they compare with established agents? Drugs 2001; 61:919.
  58. Cooper RA, Maddineni VR, Mirakhur RK, et al. Time course of neuromuscular effects and pharmacokinetics of rocuronium bromide (Org 9426) during isoflurane anaesthesia in patients with and without renal failure. Br J Anaesth 1993; 71:222.
  59. Goldberg ME, Cantillo J, Larijani GE, et al. Sevoflurane versus isoflurane for maintenance of anesthesia: are serum inorganic fluoride ion concentrations of concern? Anesth Analg 1996; 82:1268.
  60. Morio M, Fujii K, Satoh N, et al. Reaction of sevoflurane and its degradation products with soda lime. Toxicity of the byproducts. Anesthesiology 1992; 77:1155.
  61. Gonsowski CT, Laster MJ, Eger EI 2nd, et al. Toxicity of compound A in rats. Effect of increasing duration of administration. Anesthesiology 1994; 80:566.
  62. Gonsowski CT, Laster MJ, Eger EI 2nd, et al. Toxicity of compound A in rats. Effect of a 3-hour administration. Anesthesiology 1994; 80:556.
  63. Conzen PF, Nuscheler M, Melotte A, et al. Renal function and serum fluoride concentrations in patients with stable renal insufficiency after anesthesia with sevoflurane or enflurane. Anesth Analg 1995; 81:569.
  64. Conzen PF, Kharasch ED, Czerner SF, et al. Low-flow sevoflurane compared with low-flow isoflurane anesthesia in patients with stable renal insufficiency. Anesthesiology 2002; 97:578.
  65. Higuchi H, Adachi Y, Wada H, et al. The effects of low-flow sevoflurane and isoflurane anesthesia on renal function in patients with stable moderate renal insufficiency. Anesth Analg 2001; 92:650.
  66. Ebert TJ, Arain SR. Renal responses to low-flow desflurane, sevoflurane, and propofol in patients. Anesthesiology 2000; 93:1401.
  67. Nishiyama T, Aibiki M, Hanaoka K. Inorganic fluoride kinetics and renal tubular function after sevoflurane anesthesia in chronic renal failure patients receiving hemodialysis. Anesth Analg 1996; 83:574.
  68. Groudine SB, Fragen RJ, Kharasch ED, et al. Comparison of renal function following anesthesia with low-flow sevoflurane and isoflurane. J Clin Anesth 1999; 11:201.
  69. Mazze RI, Callan CM, Galvez ST, et al. The effects of sevoflurane on serum creatinine and blood urea nitrogen concentrations: a retrospective, twenty-two-center, comparative evaluation of renal function in adult surgical patients. Anesth Analg 2000; 90:683.
  70. Ebert TJ, Frink EJ Jr, Kharasch ED. Absence of biochemical evidence for renal and hepatic dysfunction after 8 hours of 1.25 minimum alveolar concentration sevoflurane anesthesia in volunteers. Anesthesiology 1998; 88:601.
  71. Ebert TJ, Messana LD, Uhrich TD, Staacke TS. Absence of renal and hepatic toxicity after four hours of 1.25 minimum alveolar anesthetic concentration sevoflurane anesthesia in volunteers. Anesth Analg 1998; 86:662.
  72. Kharasch ED, Frink EJ Jr, Zager R, et al. Assessment of low-flow sevoflurane and isoflurane effects on renal function using sensitive markers of tubular toxicity. Anesthesiology 1997; 86:1238.
  73. Bito H, Ikeda K. Closed-circuit anesthesia with sevoflurane in humans. Effects on renal and hepatic function and concentrations of breakdown products with soda lime in the circuit. Anesthesiology 1994; 80:71.
  74. Gentz BA, Malan TP Jr. Renal toxicity with sevoflurane: a storm in a teacup? Drugs 2001; 61:2155.
  75. Phillips BJ, Hunter JM. Use of mivacurium chloride by constant infusion in the anephric patient. Br J Anaesth 1992; 68:492.
  76. Beauvoir C, Peray P, Daures JP, et al. Pharmacodynamics of vecuronium in patients with and without renal failure: a meta-analysis. Can J Anaesth 1993; 40:696.
  77. Lynam DP, Cronnelly R, Castagnoli KP, et al. The pharmacodynamics and pharmacokinetics of vecuronium in patients anesthetized with isoflurane with normal renal function or with renal failure. Anesthesiology 1988; 69:227.
  78. Somogyi AA, Shanks CA, Triggs EJ. The effect of renal failure on the disposition and neuromuscular blocking action of pancuronium bromide. Eur J Clin Pharmacol 1977; 12:23.
  79. Cronnelly R, Stanski DR, Miller RD, et al. Renal function and the pharmacokinetics of neostigmine in anesthetized man. Anesthesiology 1979; 51:222.
  80. de Boer HD, Driessen JJ, Marcus MA, et al. Reversal of rocuronium-induced (1.2 mg/kg) profound neuromuscular block by sugammadex: a multicenter, dose-finding and safety study. Anesthesiology 2007; 107:239.
  81. Staals LM, Snoeck MM, Driessen JJ, et al. Reduced clearance of rocuronium and sugammadex in patients with severe to end-stage renal failure: a pharmacokinetic study. Br J Anaesth 2010; 104:31.
  82. Staals LM, Snoeck MM, Driessen JJ, et al. Multicentre, parallel-group, comparative trial evaluating the efficacy and safety of sugammadex in patients with end-stage renal failure or normal renal function. Br J Anaesth 2008; 101:492.
  83. Cammu G, Van Vlem B, van den Heuvel M, et al. Dialysability of sugammadex and its complex with rocuronium in intensive care patients with severe renal impairment. Br J Anaesth 2012; 109:382.
  84. Hoke JF, Shlugman D, Dershwitz M, et al. Pharmacokinetics and pharmacodynamics of remifentanil in persons with renal failure compared with healthy volunteers. Anesthesiology 1997; 87:533.
  85. Hill LR, Pichel AC. Respiratory arrest after cadaveric renal transplant. Eur J Anaesthesiol 2009; 26:435.
  86. Wiggum DC, Cork RC, Weldon ST, et al. Postoperative respiratory depression and elevated sufentanil levels in a patient with chronic renal failure. Anesthesiology 1985; 63:708.
  87. Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manage 2004; 28:497.
  88. Davis PJ, Stiller RL, Cook DR, et al. Pharmacokinetics of sufentanil in adolescent patients with chronic renal failure. Anesth Analg 1988; 67:268.
  89. Michelsen LG, Hug CC Jr. The pharmacokinetics of remifentanil. J Clin Anesth 1996; 8:679.
  90. Pham PT, Toscano E, Pham PT, et al. Pain management in patients with chronic kidney disease. NDT Plus 2009; 2:111. ckj.oxfordjournals.org/content/2/2/111.full.pdf+html (Accessed on November 15, 2014).
  91. Fournier JP, Azoulay L, Yin H, et al. Tramadol use and the risk of hospitalization for hypoglycemia in patients with noncancer pain. JAMA Intern Med 2015; 175:186.
  92. Davison SN, Mayo PR. Pain management in chronic kidney disease: the pharmacokinetics and pharmacodynamics of hydromorphone and hydromorphone-3-glucuronide in hemodialysis patients. J Opioid Manag 2008; 4:335.
  93. Perlman R, Giladi H, Brecht K, et al. Intradialytic clearance of opioids: methadone versus hydromorphone. Pain 2013; 154:2794.
  94. Gottschalk A, Durieux ME, Nemergut EC. Intraoperative methadone improves postoperative pain control in patients undergoing complex spine surgery. Anesth Analg 2011; 112:218.
  95. Niscola P, Scaramucci L, Vischini G, et al. The use of major analgesics in patients with renal dysfunction. Curr Drug Targets 2010; 11:752.
  96. Filitz J, Griessinger N, Sittl R, et al. Effects of intermittent hemodialysis on buprenorphine and norbuprenorphine plasma concentrations in chronic pain patients treated with transdermal buprenorphine. Eur J Pain 2006; 10:743.
  97. Angst MS, Bührer M, Lötsch J. Insidious intoxication after morphine treatment in renal failure: delayed onset of morphine-6-glucuronide action. Anesthesiology 2000; 92:1473.
  98. Mazoit JX, Butscher K, Samii K. Morphine in postoperative patients: pharmacokinetics and pharmacodynamics of metabolites. Anesth Analg 2007; 105:70.
  99. Osborne R, Joel S, Grebenik K, et al. The pharmacokinetics of morphine and morphine glucuronides in kidney failure. Clin Pharmacol Ther 1993; 54:158.
  100. Szeto HH, Inturrisi CE, Houde R, et al. Accumulation of normeperidine, an active metabolite of meperidine, in patients with renal failure of cancer. Ann Intern Med 1977; 86:738.
  101. Guay DR, Awni WM, Findlay JW, et al. Pharmacokinetics and pharmacodynamics of codeine in end-stage renal disease. Clin Pharmacol Ther 1988; 43:63.
  102. Talbott GA, Lynn AM, Levy FH, Zelikovic I. Respiratory arrest precipitated by codeine in a child with chronic renal failure. Clin Pediatr (Phila) 1997; 36:171.
  103. Matzke GR, Chan GL, Abraham PA. Codeine dosage in renal failure. Clin Pharm 1986; 5:15.
  104. Yunos NM, Bellomo R, Hegarty C, et al. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA 2012; 308:1566.
  105. Potura E, Lindner G, Biesenbach P, et al. An acetate-buffered balanced crystalloid versus 0.9% saline in patients with end-stage renal disease undergoing cadaveric renal transplantation: a prospective randomized controlled trial. Anesth Analg 2015; 120:123.
  106. Jacobi J, Bircher N, Krinsley J, et al. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med 2012; 40:3251.
  107. Feringa HH, Vidakovic R, Karagiannis SE, et al. Impaired glucose regulation, elevated glycated haemoglobin and cardiac ischaemic events in vascular surgery patients. Diabet Med 2008; 25:314.
  108. Noordzij PG, Boersma E, Schreiner F, et al. Increased preoperative glucose levels are associated with perioperative mortality in patients undergoing noncardiac, nonvascular surgery. Eur J Endocrinol 2007; 156:137.
  109. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009; 360:1283.
  110. Kurella M, Bennett WM, Chertow GM. Analgesia in patients with ESRD: a review of available evidence. Am J Kidney Dis 2003; 42:217.