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.