Renal Failure and Complications of Hemodialysis
Paul B. Jones PGY3 – May 8th
Objectives
Define renal failure
Review ED management of acute renal failure
Review indications of dialysis
Review complications of dialysis
Review some 1A pearls
Acute Renal Failure
Acute Renal Failure (ARF) is the deterioration of renal function over hours or days resulting in accumulation of toxic wastes and loss of internal hemostasis.
ED Goals
Treat underlying cause
Correct fluid derangements
Correct electrolyte derangements
Prevent further renal damage
Provide supportive care until renal function recovers
Case 1
82 year old woman from retirement home. Presents to ER with weakness and confusion. ED Basic and Urine R&M were completed by ER protocol.
WBC 6.0, Hb 118, PLT 227
Na 135, K 4.5, Cl 108, HCO3 24
Cr 200 Ur10.2
Important to check for previous Cr and Ur values for comparison.
Case 2
76 year old male admitted to hospital with diverticulitis.
PMHx – DM, HTN
Cr baseline 78
Cr today 153
Had CT with contrast 3 days prior…
Case 3
78 year old male presents with suprapubic pain and urinary incontinence over last week.
Bladder scan shows 900 ml in the bladder.
Foley cather is inserted and drains > 1L urine.
Urine + RBC, - Leuks/Nitrites
Rectal exam reveals firm nodular prostate
Anuria
For the acutely anuric patient obstruction should be a major consideration.
If no urine is obtained on initial bladder catherization , emergency urologic consultation should be considered.
Indications = AEIOU
Indications for dialysis in the patient with acute kidney injury Acidemia from metabolic acidosis in situations in which
correction with sodium bicarbonate is impractical or may result in fluid overload
Electrolyte abnormality, such as severe hyperkalemia Intoxication/acute poisoning with a dialyzable substance.
SLIME: salicylic acid, lithium, isopropanol, Magnesium-containing laxatives, and ethylene glycol
Overload of fluid not expected to respond to treatment with diuretics
Uremia complications, such as pericarditis, encephalopathy, or gastrointestinal bleeding.
AEIOU
Acidemia
Electrolyte derangement
Intoxication/poisoning with dialyzable substance
Overload of fluid
Uremic complications
Any sometimes why?
Hemodialysis
Key Elements for Dialysis
Dialyzer membrane
Access
Anticoagulation
Dialyzer Membrane
Access
Tunneled Catheter
inconvenient
infection risk
clotting
immediate use
AV Graft
clotting risk
rare infection
rapid maturation
AV Fistula
low clotting risk
no infections
slow maturation
Anatomy req
Anticoagulation
Hemodialysis History
Etiology of ESRD
Dialysis schedule? Missed sessions?
Recent complications of HD?
Dry weight, baseline labs and vital signs
Which vascular access is working?
Symptoms of uremia?
Retention of native kidneys?
Still producing urine?
Hemodialysis Complications
Vascular access related complications Bleeding Vessel Thrombosis Infection
Non-vascular complications Hypotension Acute hemorrhage Severe hyperkalemia
Uremia
Complications of HD
Hypotension
Dialysis Disequilibrium
Air Embolism
Electrolyte Abnormalities
Hypoglycemia
Peridialytic Hypotension
Excessive Ultrafiltration
Predialytic volume loss (GI losses, decreased oral intake)
Intradialytic volume loss (tube & hemodialyzer blood loss)
Postdialytic volume loss (vascular access blood loss)
Medication effects & Decreased vascular tone
Cardiac Dysfunction (LVH, Ischemia, Hypoxia, Arrhythmia)
Pericardial Disease (effiusion, tamponade)
1 A PEARLS
We recommend not using low-dose dopamine to prevent or treat AKI. (1A)
We recommend monitoring aminoglycoside drug levels when treatment with multiple daily dosing is used for more than 24 hours. (1A)
In the treatment of system mycoses or parasitic infections we recommend using azole antifungal agents and/or the echinocandins rather than conventional amphotericin B if equal therapeutic efficacy can be assumed. (1A)
We recommend not using oral or IV NAC for prevention of postsurgical AKI. (1A)
We recommend IV volume expansion with either isotonic sodium chloride or sodium bicarbonate solutions, rather than no IV volume expansion, in patients at increased risk for CI-AKI. (1A)
Other Pearls
In the absence of hemorrhagic shock we use isotonic crystalloids rather than colloids (albumin or starches) as initial management for expansion of the intravascular volume in patients at risk for AKI or with AKI (2B)
References
Joel Topf, MD Clinical Nephrologist. Dialysis for the Internist: An Update. 2011. aka @Kidney_boy
Chapter 92. Acute Renal Failure. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e, 2011
Chapter 93. Emergencies in Renal Failure and Dialysis Patients. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e, 2011
References
Allan B. Wilfson C. Chapter 95 Renal Failure. PART III / Medicine and Surgery / SECTION SIX • Genitourinary and Gynecologic Systems. Rosen’s Emergency Medicine – Concepts and Clinical Practice.
Sterns RH, Rojas M, Bernstein P, Chennupati S. Ion-exchange resins for the treatment of hyperkalemia: are they safe and effective? J Am Soc Nephrol. 2010 May;21(5):733-5. doi: 10.1681/ASN.2010010079. Epub 2010 Feb 18.
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1-138.