Mr.K. 70 yrs with long standing diabetes.He first developed diabetic nephropathy & renal failure & 2 silentmyocardial infarctions. Leading to reduced heart function 30%. Renal parametersshowed raised Sr. Creatinine of 2.4 requiring large doses of diuretics. He was admitted in ICU with Leftventricular failure. He underwent aggressive anti-failure treatment with NIV.After optimal medical stabilisation by diuretics, inotropes, & diabetescontrol & underwent angiography showing severe TVD involving LM stem 70%,LAD – 100%, RCA-100%, OM2-90%, D2-100% block. He was advised CABG.CABG was complex & highlyrisky due to multiple organ dysfunctionlike deranged kidney function, poor heart & Lung functions. In this case it is veryimportant to have critical management by cardiac anaesthesia so as to not have hypotension & adverse drugreactions, intraoperative fluid & electrolyte management & hemodynamicmanagement while coronary revascularisation is being done. Here due to leftmain CAD It was pre-decided to do this case on cardiopulmonary bypass &using hemodialyzer to support kidney function & electrolyte management. Useof Swan-Ganz catheter helps in hemodynamic , inotrope & fluid management.Continuous diuretic infusion & insulin infusion was also done. Patientreceived four vessel coronary arterybypass graft utilising left IMA & saphenous veins in a short 50 mts CPB& blood cardioplegic myocardial protection. There was smooth wean off fromCPB with out any problems. Minimum inotrope support was required for stablehemodynamics & patient was transferred to ICU in good condition . Hewas safely weaned off ventilator nextday & discharged on 7th post operation day. Optimal medical management inthese complex multiorgan dysfunctions is important to make patient fit to undergo CABGsafely. Understanding multiorgan dysfunction & use of current supportsystem for preservation of kidney, Lung, & heart during operation precludesany inotropes, IABP , wound infection, renal shutdown like morbidities &provides successful outcome. I have developed special protocolfor these renal failure patients to undergo safe CABG & results have beenrewarding. ��Г