Safety and recovery of rocuronium and sugammadex versus cisatracurium or atracurium and pyridostigmine in surgical patients with chronic kidney disease: a multi-center retrospective propensity score-matched study

Background: Rocuronium and sugammadex are used cautiously in patients with chronic kidney disease (CKD) undergoing anesthesia because of delayed excretion. This multicenter retrospective study explored the safety and recovery of rocuronium–sugammadex compared to cisatracurium/atracurium–pyridostigmine in patients with CKD.Methods: Patients with CKD who received rocuronium–sugammadex (RS group) or cisatracurium/atracurium–pyridostigmine (CP group) between 2020 and 2021 at three tertiary referral hospitals were included. Propensity score-matching was performed using a logistic regression model. The primary outcomes were safety-related indicators (e.g., reintubation, deferred extubation, and desaturation). Secondary outcomes included recovery-related profiles (e.g., extubation time). Subgroup analyses were conducted according to the CKD stage.Results: Of the total 1,241 patients (RS = 630, CP = 611), 804 (402 per group) were matched and analyzed. Among them, 51.1% had advanced CKD (estimated glomerular filtration rate < 30 ml/min/1.73 m2). Primary safety outcomes, including the incidence of reintubation within 48 h (RS: 1.24% vs. CP: 1.24%, P = 1.000) and deferred extubation (1.74% vs. 1.49%, P = 0.780), were not significantly different. Postoperative desaturation and renal outcomes were similar between groups. Extubation time was shorter in the RS group than in the CP group (median 7.00vs. 8.00 min, P = 0.005).Conclusions: Rocuronium–sugammadex demonstrated no clear signal of increased major respiratory or renal risk compared with cisatracurium/atracurium–pyridostigmine in patients with CKD. Although the extubation time was shorter in the RS group, this exploratory finding must be interpreted cautiously because of the heterogeneous practice and limited quantitative neuromuscular monitoring (22%).