Efficacy and safety of sugammadex in patients with living kidney transplantation due to end-stage renal disease and rocuronium used for neuromuscular blockade

Objective: Sugammadex (Bridion®) is a modified cyclodextrin designed to selectively encapsulate aminosteroidal neuromuscular blocking agents (NMBAs) such as rocuronium and vecuronium, resulting in rapid reversal of neuromuscular blockade (NMB). The sugammadex-NMBA complex produced is inactive and hydrophilic and is primarily excreted by the kidneys. The pharmacokinetics of both rocuronium and sugammadex may be altered in patients with severe renal maintenance, and therefore, NMB recycling with sugammadex may be unpredictable or incomplete. Although some case reports in the literature report the safety of rocuronium and sugammadex in kidney transplantation, exposure to sugammadex during kidney transplantation is insufficient, and available safety data are lacking. This is an ongoing effort to retrospectively investigate the safety and reliability of sugammadex in the perioperative period and close follow-up of living donor kidney transplants. Materials and Methods: The study included 158 adult patients who underwent living donor kidney transplantation surgery at Akdeniz University Faculty of Medicine Prof. Dr. Tuncer Karpuzoğlu Organ Transplantation and Robotic Surgery Center between 01.01.2019 and 13.09.2022. The data of the patients were obtained from patient follow-up files and hospital information system database. Demographic data of the patients, parameters such as duration of anesthesia, duration of surgery, duration of stay in the Post-Anesthesia Care Unit (ASCU) and discharge time, drugs and fluids used, blood and blood products, perioperative dialysis information, intraoperative and postoperative blood gas values (pH, pO2, pCO2, HCO3, Hb, O2 saturation, lactate), preoperative and postoperative 1st, 2nd, 3rd and 7th days and postoperative 1st month renal function tests (creatinine, GFR, BUN, proteinuria), perioperative vital findings, and muscle weakness and respiratory complications that may develop due to muscle weakness in the postoperative period were recorded. The patients were evaluated by dividing into groups according to whether sugammadex was used and whether they were transferred to the ward or transferred to the ASCU after postoperative recovery. Results: This study aimed to evaluate the effect of the use of sugammadex at the recommended doses for reversal of rocuronium-induced neuromuscular blockade on renal function and postoperative respiratory complications compared to the control group without sugammadex. In patients with sugammadex, day 1 creatinine values were significantly higher and day 1 and day 2 eGFR values were significantly lower than in patients without sugammadex. Creatinine and eGFR values measured at other times were not found to be different between the groups. Postoperative HCO3 and lactate values were measured significantly lower in patients with sugammadex and this difference was found to be statistically significant. When we examined the biological characteristics of the groups we determined in our study, it was seen that the frequency of postoperative ASBU transfer increased with increasing age and the presence of CVD (p=0.001). In the correlation analyses; There was no significant correlation between postoperative pO2 value and 3rd day creatinine value (p=0.071), while a low-level significant correlation was observed between 3rd day eGFR in the same direction (r=0.168; p=0.037). A low-level significant correlation was observed between postoperative pO2 value and 3rd day BUN value in the opposite direction (r=-0.291; p<0.001). The mean 7th day creatinine value was found to be significantly lower in patients who were administered sugammadex above 4 mg/kg than in patients who were administered sugammadex 2-4 mg/kg. No muscle weakness related to recurarization or respiratory complications related to muscle weakness were reported in the postoperative follow-up in any of the patients included in the study. Conclusion: The results obtained show that sugammadex effectively reverses both moderate and deep rocuronium-induced NMB and does not make a significant difference in overall postoperative complication rates. The short-term effects of sugammadex on renal function are minimal and can be considered as a generally safe and effective option. Our study demonstrates the need for larger and longer-term studies to better understand the effects of sugammadex in clinical practice.