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Emergencies in Renal Failure and Dialysis Patients. Tintinalli chapter 93. ESRD: irreversible loss of renal function, accumulation of toxins and loss of internal homeostasis. Uremia: clinical syndrome resulting from ESRD. Epidemiology. 1999=89,252 new cases/424,179 patients being tx for ESRD

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slide2
ESRD: irreversible loss of renal function, accumulation of toxins and loss of internal homeostasis.
  • Uremia: clinical syndrome resulting from ESRD.
epidemiology
Epidemiology
  • 1999=89,252 new cases/424,179 patients being tx for ESRD
  • Causes: DM=#1, HTN=#2
  • Therapy: dialysis=70%
    • transplants=30%
  • ESRD deaths: 50% cardiac causes.
    • 10-25% infectious
  • Survival rates for 1,2,5 yrs= 79, 65, 34 % respectively
pathophysiology of uremia
Pathophysiology of Uremia
  • Excretory Failure: causes >70 chemicals to elevate. Urea= major breakdown of proteins. Limit protein intake
  • Biosynthetic Failure: loss of hormones 1,25(OH)3 vit D3 and erythropoietin.
    • 85% of erythropoietin produced by kidney.
    • Vit. D3 deficiency= secondary hyperparathyroidism, renal bone disease.
pathophysiology of uremia5
Pathophysiology of Uremia
  • Regulatory Failure: over secretion of hormones , disruption of normal feedback mechanisms
clinical features of uremia
Clinical Features of Uremia
  • Neurologic complications:
  • Subdural hematoma: 3.5% of ESRD, HTN, head trauma, bleeding dyscrasias, anticoagulants, ultrafiltration.
  • Uremic Encephalopathy: nonspecific centreal neurologic symptoms, responds to dialysis.
slide7
Neurologic complications:
  • Dialysis Dementia: like uremic encephalopathy but progressive and fatal, seen after 2 years on dialysis
  • Peripheral neuropathy: >50% of HD patients. “glove and stocking pattern”, improves after transplant
  • Autonomic dysfunction: common; dizzy, impotence, bowel dysfunction.
slide8
Cardiovascular complications: prevalence is greater in ESRD
  • d/t pre-existing conditions, uremia, toxins, high lipids, homocystine, hyperparathyroidism, dialysis related conditions
slide9
General population

CAD: 12%

LV hypert. 20%

CHF 5%

ESRD

40%

75%

40%

slide10
Creatine protein Kinase &MB, Troponin I and T…….NOT significantly elevated in patients undergoing regular dialysis, have been shown to be specific markers in these patients.
slide11
HTN: 80-90% of ESRD starting dialysis. d/t volume, vasopressor effects of kidney, RAS system. Tx initially w/ volume control
  • CHF: HTN #1 cause in ESRD.
  • Uremic cardiomyopathy: dx of exclusion when other causes of CHF ruled out.
slide12
Pulmonary Edema: fluid overload, MI.
    • Tx w/ O2, nitrates, ACE inhib, morphine, diuretics. Can also use phlebotomy, dialysis.
  • Cardiac Tamponade: rarely w/ classic presentation of low BP, muffled sounds and JVD.
    • Echocardiography, pericardiocentisis
slide13
Pericarditis/ Uremic Pericarditis:
  • Uremic more common=75%
  • Fluid overload, abnl platelet function, ↑ fibrinolytic and inflammatory cell activity
  • Friction Rubs= louder, palpable, persist after metabolic abnormality resolved
  • BUN always>60 mg/dl
  • Absent EKG changes
slide14
Dialysis related percarditis: recurrent, most common type during dialysis. More common adhesions and fluid loculations
  • ESRD w/ pericarditis= 8%
  • Tx w/ dialysis
  • Avg survival without dialysis= 1 month
slide15
Hematologic Complications:
  • Anemia: low erythropoietin, blood loss from dialysis, ↓ RBC survival times
    • Normocytic, normochromic
    • Hct stabilizes @ 15-20 without tx.
    • Tx=erythropoietin
slide16
Bleeding diathesis: ↑ risk of GI bleed, subdural.
    • Can try tx with desmopressin
  • Immunologic deficiency: leukocyte chemotaxis and phagocytosis decreased in uremic state.
    • Dialysis does not help immune function.
slide17
GI complications:
  • Anorexia, nausea, vomiting=common in uremia
  • Increased GI bleeding
  • Chronic constipation
  • Ascites from portal HTN, polycystic liver ds., fluid overload.
slide18
Renal Bone Disease:
  • Systemic calcification; ↓ GFR=↑ serum phosphate levels.
    • Pseudogout, metastatic calcification of tissues, vessels.
    • Tx=low Ca dialysate and phosphate-binding gels
slide19
Hyperparathyroidism (Osteitis Fibrosa Cystica);
    • ↓ ionized Ca=↑ PTH= high bone turnover, weak bones.
    • Tx=phosphate binding gels, Vit D3 replacement, subtotal parathyroidectomy
slide20
Osteomalacia; defect in bone calcification
  • d/t Vit.D3 deficiency and aluminum intoxication
  • Weakened bones, muscle pains, weakness
  • Low PTH, ow to normal alkaline phosphate levels, ↑ serum aluminum
  • Tx= desferrioxamine
slide21
Β2-Microglobulin amyloidosis:
  • Pts >50 yrs old, on dialysis >10 yrs
  • Amyloid deposits in GI tract, bones, joints.
  • Complications; GI perfs, bone fx’s, carpal tunnel, rotator cuff tears.
  • Pts w/ amyloidosis have ↑ mortality rates
hemodialysis
Hemodialysis
  • Uses ultrafiltration and clearance to replace nephron.
  • Solute removal depends on filter pore size and concentration gradient
  • Heparin 1000-2000 units typically used
  • Sessions take @ 3-4 hrs.
vascular access complications
Vascular Access Complications
  • Types of Access:
  • 1. A-V fistula
  • 2. Vascular graft: higher complication rates, shorter functional lifes.
  • 3. Tunnel-cuffed catheters; Hickman, Quinton
slide24
Thrombosis and Stenosis of Access:
  • Most common complication
  • Loss of bruit and thrill
  • Stenosis / thrombosis: not Emergencies= tx w/in 24 hours.
slide25
Vascular Access Infections:
  • 2-5% of fistulas, 10% of grafts
  • Often signs of sepsis, fever, Hypotension, ↑ WBC
  • Erythema, swelling, discharge at site often missing.
  • Staph Aureus #1, gram neg #2
  • Vanc is drug of choice, usually add Gent.
slide26
Hemorrhage:
  • d/t aneurysm, anastomosis rupture or over anticoagulation.
  • Direct pressure
  • Protamine 10-20 mg or 0.01 mg/unit hep.
  • Consult surgery or nephrology
slide27
Vascular access aneurysms:
  • Repeated punctures
  • Bulging in wall
  • Rarely rupture
  • True aneurysms very rare; 4% of fistulas
slide28
Vascular access pseudoaneurysm:
  • Subcutaneous extravasation of blood
  • Present w/ bleeding & infection at site
slide29
Vascular insufficiency: distal to access
  • “steal syndrome”
  • Preferential shunting of blood to low pressure venous side
  • s/s exercise pain, non-healing ulcers, cool pulseless digits
  • Dx w/ doppler or angiography
slide30
High-output heart failure:
  • When 20% of cardiac output diverted through access
  • Branham sign: drop in HR after temporary access occlusion
  • Doppler to measure access flow rate
  • Surgical banding of access is Tx.
complications during hemodialysis
Complications During Hemodialysis
  • 1. Hypotension:
  • Most frequent, 10-20% of treatments
  • Dialysis can remove up to 2 L/hr.
  • Cardiac compensation limited d/t ↓ diastolic function common in ESRD
  • Abnormalities in vascular tone; sepsis, anit HTN meds, ↑ nitric oxide
slide32
Early hypotension: pre-existing hypovolemia
  • Peridialysis losses; starts HD below dry weight; d/t sepsis, GI bleed, vomiting, diarrhea, decreased salt/water intake
  • Intradialytic blood loss from tubing/dialyzer leads
  • Hypotension at end of dialysis: excessive removal, cardiac or pericardial disease.
slide33
Intradialytic hypotension:
  • N/V/anxiety, ortho hypotension, tachycardia, dizzy, syncope.
  • Tx.; stop HD, Trendelenburg. Salt, broth by mouth, NS 100-200 cc. IV.
  • If these fail look for other causes than excessive fluid removal
slide34
2. Dialysis disequilibrium:
  • End of dialysis
  • N/V, HTN...progress to coma, seizure and death
  • d/t cerebral edema after large solute clearance in HD
  • Tx. Stop HD, administer Mannitol IV.
slide35
3. Air Embolism:
  • s/s: dyspnea, chest tightness, unconscious, full cardiac arrest. Cyanosis, churning sound in heart from bubbles
  • Clamp venous blood line, place supine
  • Other Tx’s: percutaneous aspiration from R ventricle, IV steroids, full heparinization, hyperbaric O2 treatment
slide36
4. Electrolyte abnormalities:
  • ↑ Ca, ↑Mg
  • N/V, HA, burning skin, weakness, lethargy HTN
  • 5. Hypoglycemia
evaluation of hd patients
Evaluation of HD Patients
  • Dialysis schedule
  • Dry weight
  • Length of dialysis
  • Inspect access site; erythema, swelling, tender, discharge.
  • Peripheral edema, HJR, JVD not always CHF
  • Murmurs; high flow d/t anemia?
peritoneal dialysis
Peritoneal Dialysis
  • Peritoneal membrane= blood-dialysate interface
  • Can be done acutely, chronically(continuous)=4 times/day, or multiple exchanges at night while sleeping.
complications
Complications
  • Peritonitis #1
  • Mortality 2.5-12.5 %
  • Fever, abd pain, rebound tender
  • Dialysate fluid for cell count, Gram stain, culture
  • Staph epidermidis 40%, S. aureus 10%, Strep species 15-20%, gram neg bacteria 15-20%, anaerobic bacteria 5%, fungi 5%.
slide40
Empiric antibiotic therapy
  • Add to dialysate
  • Parenteral administration not needed
  • Rapid exchanges of fluid lavage to wash out inflammatory cells
  • First gen Ceph
  • Vanc if pen allergic
  • Can add Gent
slide41
Infections around PD catheter site:
  • Pain, erythema, swelling, discharge.
  • S. aureus, Pseudomonas aeruginosa
  • Empiric w/ first generation Ceph or Cipro
  • Outpatient therapy with f/u at CAPD center next day
slide42
Abdominal wall hernia
  • 10-15%
  • Highest rate of incarcerating
  • Immediate surgical repair
overview evaluating pd patient
Overview Evaluating PD Patient
  • Type and frequency of dialysis
  • Date of last episode of peritonitis
  • Frequency of relapse infections
  • Baseline weight
  • Focus on abdomen and catheter tunnel
questions
Questions:
  • 1. T/F Peripheral Neuropathy, “stocking and glove pattern”, is rarely seen in ESRD pts on dialysis.
  • 2. T/F ESRD patients carry the same cardiovascular risk as general population.
  • 3. T/F Troponins are commonly significantly elevated in patients on regular dialysis and cannot be trusted as cardiac marker.
slide45
4. #1 cause of dialysis access site infections…
    • A. klebsiella
    • B. staph aureus
    • C. strep species
    • D. E. coli
slide46
5. #1 complication during dialysis sessions is ….
    • A. hypotension
    • B. fever
    • C. CHF
    • D. cough

Answers: false (seen in 50%), false(inc risk), false, B, A.