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Background/aims: The optimal preoperative management of patients with acute obstructive jaundice is still a matter of debate. Reduction in effective plasma volume and systemic endotoxemia are major consequences both in experimental acute bile duct ligation and in patients with acute obstructive jaundice (AOJ). The objective of this study is to show the necessity for adequate preoperative hydration and lactulose administration for the prevention of postoperative renal dysfunction in patients with AOJ., Methodology: Fifty-five patients (35 male, 20 female) with a mean age of 62 years were entered into the study. There were 23 benign and 32 malignant strictures in this group. All patients received oral lactulose (30-45mL per day) and IV cefazoline (3-4g/day) before surgery. Fluid and electrolyte balance was precisely maintained throughout the hospitalization via daily body weight calculations. High-risk elderly patients with left ventricular systolic dysfunction were assessed by echocardiography and therapeutic measures were undertaken. Renal function was assessed by creatinine clearance (ClCr) measurements and impairment of renal function was defined as a >20% fall in ClCr value post-surgery., Results: Mean preoperative bilirubin level was 11.05mg/dL (range: 3.45-27.0mg/dL). None of the patients developed postoperative renal failure. The difference between pre- and postoperative ClCr value (104.02mL/min vs. 101.0mL/min respectively) was not significant (t=0.698, P=0.489). One patient with mild renal function impairment before surgery (ClCr=45.4mL/min) successfully recovered with 60% rise in creatinine clearance (ClCr=78.1mL/min) after the operation. Three patients with normal functioning kidneys died within 30 days of operation. The principle cause of death was carcinomatosis and pulmonary embolus in two and intraoperative hemorrhagic shock in one patient., Conclusions: These results further substantiated the importance of adequate preoperative hydration and endotoxin inactivation in terms of acute renal failure prophylaxis in patients with AOJ. This regimen obviates the afferent events in obstructive jaundice and provides prevention of acute renal failure even in high-risk elderly patients.