Patients with end stage renal failure (ESRF) present a number of challenges to the anesthesiologist. They may be chronically ill and debilitated and have the potential for multisystem organ dysfunction. Patients with primary renal disease are likely younger and have good cardiopulmonary reserve. Older patients with renal failure secondary to diabetes mellitus or hypertension may suffer the ravages of diffuse atherosclerosis and heart disease. To safely manage these patients we need to understand the benefits and limitations of dialysis, problems related with primary disease, pathophysiological effects of ESRF, and the altered pharmacology of commonly used anesthetic agents and perioperative medications in ESRF. Problems encountered by anesthesiologist in ESRF patients include hypertension, ischemic heart disease, congestive heart failure, anemia, metabolic acidosis, hyperkaliemia, hyponatremia and circulatory collapse. All surgical procedure in patients with ESRF carries significant risk of peri- and postoperative complications (mostly cardiovascular) and even fatal outcome.