Management of the Sick Dialysis/ESRD Patient

Authors: John Paik, MD and Christine Kulstad, MD (EM Resident Physician and Attending Physician, Advocate Christ Medical Center) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Stephen Alerhand, MD (@SAlerhand)

Case 1

You receive a call from the charge nurse who says you have a new patient in room 4B. He is here with generalized weakness. The patient is being hooked up to the monitor and the HR is 38. The BP is pending. The patient’s family looks concerned due to the low heart rate alarm. Two nurses are looking at you for orders. You ask for atropine as your attending walks into the room.

Case 2

An hour later, your co-resident is assigned a patient brought in by EMS complaining of difficulty breathing. The patient is speaking in full sentences but is very tachypneic. You decide to help your co-resident and bring in the ultrasound. You notice B-lines, then get a phone call and have to step away from the room. You first relay this information to your co-resident, and you both agree it likely represents volume overload from a missed dialysis session. After you are done with your phone call, you hear assistance is required in room 5, and you rush over to see what is happening with the patient.

Introduction

End-stage renal disease (ESRD) continues to grow as a public health problem. According to the United States Renal Data System, there were 636,905 cases of ESRD in the U.S. as of December 31, 2012, which was a 3.7% increase compared to the previous year. The number of people receiving hemodialysis (HD) or peritoneal dialysis (PD) has reached 449,342, a 57.4% increase compared to 2000[1]. These patients encounter a range of complications and are oftentimes sent to the Emergency Department for further evaluation. We will discuss a few of common complications in this article.

Cardiopulmonary

Cardiac tamponade is a life-threatening disease that an EM doc should be mindful of in the patient with hypotension and dyspnea. Assuming the patient’s dyspnea is from a missed dialysis session or the natural course of the patient’s disease is a common pitfall. One should also be mindful that Beck’s triad (hypotension, distended neck veins, muffled heart sounds) is only seen in a minority of cardiac tamponade cases and this applies even more to ESRD patients[2]. A quick bedside ultrasound can detect a significant pericardial effusion and essentially exclude the diagnosis if normal[3]. A chest x-ray may also show an enlarging heart size when compared to a previous chest x-ray. Electrical alternans on EKG would also clue in the ED physician of significant pericardial effusion, however, its absence does not rule out an effusion. If this diagnosis is identified, cardiology or cardiothoracic surgery consultation should be obtained immediately. If the patient is hypotensive, IV fluids should be provided. If the patient is in a peri-arrest state, then the ED physician should perform a pericardiocentesis.

Chest pain is also a common complaint, and it is estimated that ischemic heart disease accounts for approximately 50% of deaths in ESRD patients[4]. While ESRD patients generally have abnormal EKGs, new ST changes should be acted on immediately. Troponin elevation can occur due to reduced renal clearance. However, previous troponin levels should be compared and elevated troponin should not be automatically attributed to ESRD. If the ESRD patient has acute coronary syndrome, no dose adjustments are required for aspirin, clopidogrel, heparin, or thrombolytics if they are being considered. However, if enoxaparin is to be started, dosage adjustments are required⁴.

In the setting of cardiac arrest, hyperkalemia should be the first of the “Hs and Ts” on the differential. This can be treated with calcium gluconate or calcium chloride and sodium bicarbonate. A stat VBG/ABG can confirm hyperkalemia. Otherwise, the patient should be treated as any patient with cardiac arrest without a history of ESRD.

Common EKG changes of hyperkalemia classically occur in a progressive fashion: peaked or tall T waves, shortening QT interval, lengthening of the PR segment, followed by widening of the QRS wave that eventually turns into a “sine wave.”[5] However, in one study looking at various hemodialysis emergencies in the ED, only 45.45% of the cases had classic EKG findings. Therefore, EKG alone should never be used to rule out hyperkalemia[6]. Furthermore, EKG changes do not correlate with the patient’s potassium level. Dr. Amal Mattu christened hyperkalemia the “syphilis of electrocardiography” because of its ability to produce almost any EKG finding[7]. Unexplained rhythm abnormalities should be considered as hyperkalemia in the HD patient until proven otherwise.

The most common cause of dyspnea in dialysis patients is pulmonary edema or volume overload. The patient may have missed dialysis, have uncontrolled high blood pressure, ignored dietary restrictions, or have underlying systolic dysfunction. Brain natriuretic peptide (BNP) is not a reliable serum marker for diagnosing heart failure as it is usually elevated in this population⁴. Inquiring about missed dialysis, dietary indiscretions, and especially any recent weight gains can clue the ED physician that volume overload may be the cause of the patient’s dyspnea. If IV access is problematic and the patient is normotensive, sublingual nitroglycerin and non-invasive ventilation can reduce pre- and afterload[8]. Once IV access is obtained, a nitroglycerin infusion can be started. Ultimately, these measures only provide symptomatic relief and urgent hemodialysis should be arranged for the patient. Vascular access is also a common problem in dialysis patients. The hemodialysis access site should not be used except as a last resort in critical situations. Blood pressure recording is also contraindicated over the access site⁴.

Pharmacology

ESRD patients typically have some degree of anemia due to a deficiency in erythropoietin produced by the kidney. If blood transfusion is required, it should occur during dialysis to correct for the extra volume as well as potassium changes⁴.

If analgesia is required, nonsteroidal anti-inflammatory agents should be avoided. Opioids such as morphine and hydromorphone should be started at a dose reduced by approximately 50%. Most antibiotics are efficacious and may require dosage adjustment, but nitrofurantoin should be avoided[9]. If the ESRD patient requires contrast for radiographic evaluation, the ED physician can order the necessary studies without concern for renal injury⁴.

If a decision is made to intubate a HD patient, succinylcholine should be avoided if the potassium level is not yet known. Succinylcholine causes potassium efflux after binding to skeletal nicotinic receptors, thus causing a rise in potassium. While this rise in potassium is usually inconsequential, this rise from succinylcholine can cause dysrhythmia in patients with hyperkalemia. A previous emDocs article talks about this further, as well as some other advantages to using rocuronium as your RSI paralytic of choice.[10]

Infectious Disease

Patients on dialysis are immunosuppressed, making infection a common concern. Clinical presentations for common infectious diseases are not always straightforward, i.e. patients may only complain of generalized weakness or fatigue and can be afebrile⁸. Infection of the access site is a common complication. Patients with catheters are at increased risk compared to patients with fistulas. If a new murmur is detected on your physical exam in the setting of fever, one must consider endocarditis. Patients with back pain without apparent cause raise the possibility of diskitis or osteomyelitis due to hematogenous spread⁴. Urinary tract infections have been diagnosed in dialysis patients who are essentially anuric as well[11]. ESRD patients with fever should get a CBC, chest x-ray, and 2 sets of blood cultures prior to antibiotic therapy. If there is concern for an infection at the access site, the catheter should be removed and sent for culture. Patients with suspected infection should be admitted and have empiric antibiotic therapy covering for both MRSA and gram negative organisms started.

For patients with continuous ambulatory peritoneal dialysis (CAPD), peritonitis is a common cause of fever. Common symptoms include diffuse abdominal pain/tenderness, cloudy dialysate, with nausea and/or vomiting. The most common organisms are Strep and Staph species. However, one study reported 15-20% gram-negative organisms as well as another 15-20% culture negative⁴. If one suspects CAPD-associated peritonitis, the dialysate should be sent for WBC count with differential, gram stain, and culture. Gram stains are usually negative, but still should be performed as it may show the presence of yeast. If yeast is detected, antifungal therapy should be initiated and the catheter removed[12]. Fungal and mycobacterial species have been isolated in about 1-2% of CAPD-associated peritonitis⁴. WBC count greater than 100/uL with > 50% PMNs suggests peritonitis. Begin empiric antibiotic therapy to cover gram positive and gram-negative organisms. The preferred route of administration is intraperitoneal as it is superior to intravenous administration¹².

Neurology

Neurologic complaints such as headache, confusion, and altered mental status (AMS) are common. The most common cause is dialysis disequilibrium syndrome (DDS), which is thought to occur from removal of blood urea nitrogen and other uremic wastes during HD. This subsequently leads to a decrease in serum osmolality and water to shift into brain tissue, causing cerebral edema. A clue that DDS is the cause of the patient’s headache is if the patient’s symptoms started during or shortly after HD. Treatment is supportive, with the nephrologist making adjustments such as a shorter hemodialysis session. Other causes of headache and AMS include intracranial hemorrhage made more likely by platelet dysfunction. Subdural hematomas occur 10 times more frequently in HD patients than the general population. Subdural hematomas can be bilateral and can occur without any focal deficits. Strokes are also common in HD patients with 52% of these being hemorrhagic[13]. Therefore, neuroimaging should be considered in all HD patients presenting with headache or AMS.

Case Conclusion

Case 1:

Your attending somehow immediately knew the patient was a dialysis patient. She asks for an amp of calcium gluconate and sodium bicarbonate while ordering your RT to get a VBG with stat K. The patient’s K+ is 8.2 and you order 10 units of insulin with 2 amps of D50, an albuterol 20mg neb, and you get the patient’s nephrologist on the phone to arrange emergent dialysis. Because the patient will receive dialysis within an hour, you convince the nephrologist to hold off on sodium polystyrene. Prior to the patient leaving the ED, you see the patient’s HR is now in the 70s. The patient is dialyzed and eventually leaves the hospital without any neurologic deficits.

Case 2:

The patient’s vital signs are BP 84/50, HR 119, RR 30 with O2 sat of 96% on 2L NC. No JVD is apparent, but you decide to perform a bedside ECHO to rule out tamponade. An obvious pericardial effusion with paradoxical septal wall motion is present and your co-resident orders a one-liter bolus and cancels the nitroglycerin order. The patient’s BP improves after the IVF and the cardiothoracic surgeon is called in for an emergent pericardial window.

References:

[1] Saran R, Li Y, Robinson B, et al. US Renal Data System 2014 annual data report: epidemiology of kidney disease in the United States. Am J Kidney Dis. 2015;66(1)(suppl 1):S1-S306.
[2] Sternbach G (1988). “Claude Beck: cardiac compression triads”. J Emerg Med 6 (5): 417–9
[3] Mandavia DP, Hoffner RJ, Mahaney K, et al. Bedside echocardiography by emergency physicians. Ann Emerg Med. Oct 2001;38:377-382
http://www.ncbi.nlm.nih.gov/pubmed/11574793
[4] Venkat A, Kaufmann KR, Venkat KK. Care of the end-stage renal disease patient on dialysis in the ED. Am J Emerg Med. 2006 Nov;24(7):847-58.
[5] Slovis C, Jenkins R. Conditions not primarily affecting the heart. BMJ : British Medical Journal. 2002;324(7349):1320-1323.
[6] Ahmad Z. Hyperkalemia as a medical emergency in patients with ESRD on hemodialysis. Pak J Med Sci 2010;26(1):117-122
[7] http://epmonthly.com/article/ecg-pearls-beware-the-slow-mimics-of-ventricular-tachycardia/
[8] Harwood-Nuss’ Clinical Practice of Emergency Medicine
[9] Gabardi S, Abramson S. Drug dosing in chronic kidney disease. Med Clin North Am 2005;89(3):649-87
[10] http://www.emdocs.net/roc-rocks-sux-sucks-rocuronium-agent-choice-rsi/
[11] Chaudhry A, Stone WJ, Breyer JA. Occurrence of pyuria and bacteriuria in asymptomatic hemodialysis patients. Am J Kidney Dis. 1993;21:180–183
[12] Li PK, et al. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int. 2010 Jul-Aug;30(4):393-423.
[13] Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e
¹⁴ http://www.ncbi.nlm.nih.gov/pubmed/26467100