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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 • 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
• 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 Uremia • Regulatory Failure: over secretion of hormones . disruption of normal feedback mechanisms .

• Uremic Encephalopathy: nonspecific centreal neurologic symptoms. anticoagulants. head trauma. HTN.5% of ESRD. bleeding dyscrasias. . responds to dialysis. ultrafiltration.Clinical Features of Uremia • Neurologic complications: • Subdural hematoma: 3.

dizzy. “glove and stocking pattern”. improves after transplant • Autonomic dysfunction: common. . bowel dysfunction.• Neurologic complications: • Dialysis Dementia: like uremic encephalopathy but progressive and fatal. seen after 2 years on dialysis • Peripheral neuropathy: >50% of HD patients. impotence.

dialysis related conditions . uremia. homocystine. toxins. hyperparathyroidism. high lipids.• Cardiovascular complications: prevalence is greater in ESRD • d/t pre-existing conditions.

20% CHF 5% • • • • ESRD 40% 75% 40% .• • • • General population CAD: 12% LV hypert.

• Creatine protein Kinase &MB. .NOT significantly elevated in patients undergoing regular dialysis. Troponin I and T……. have been shown to be specific markers in these patients.

• Uremic cardiomyopathy: dx of exclusion when other causes of CHF ruled out. . RAS system.• HTN: 80-90% of ESRD starting dialysis. Tx initially w/ volume control • CHF: HTN #1 cause in ESRD. d/t volume. vasopressor effects of kidney.

– Tx w/ O2. – Echocardiography. pericardiocentisis . MI. muffled sounds and JVD. • Cardiac Tamponade: rarely w/ classic presentation of low BP. ACE inhib. nitrates. diuretics. dialysis. Can also use phlebotomy. morphine.• Pulmonary Edema: fluid overload.

↑ fibrinolytic and inflammatory cell activity • Friction Rubs= louder.• Pericarditis/ Uremic Pericarditis: • Uremic more common=75% • Fluid overload. abnl platelet function. persist after metabolic abnormality resolved • BUN always>60 mg/dl • Absent EKG changes . palpable.

• 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 .

• Hematologic Complications: • Anemia: low erythropoietin. ↓ RBC survival times – Normocytic. blood loss from dialysis. normochromic – Hct stabilizes @ 15-20 without tx. – Tx=erythropoietin .

subdural. – Can try tx with desmopressin • Immunologic deficiency: leukocyte chemotaxis and phagocytosis decreased in uremic state. – Dialysis does not help immune function. .• Bleeding diathesis: ↑ risk of GI bleed.

fluid overload.• GI complications: • Anorexia. . polycystic liver ds. vomiting=common in uremia • Increased GI bleeding • Chronic constipation • Ascites from portal HTN. nausea..

• Renal Bone Disease: • Systemic calcification. – Pseudogout. metastatic calcification of tissues. – Tx=low Ca dialysate and phosphate-binding gels . ↓ GFR=↑ serum phosphate levels. vessels.

Vit D3 replacement. weak bones. – Tx=phosphate binding gels.• Hyperparathyroidism (Osteitis Fibrosa Cystica). subtotal parathyroidectomy . – ↓ ionized Ca=↑ PTH= high bone turnover.

defect in bone calcification • d/t Vit. weakness • Low PTH. ow to normal alkaline phosphate levels. muscle pains.D3 deficiency and aluminum intoxication • Weakened bones. ↑ serum aluminum • Tx= desferrioxamine .• Osteomalacia.

• • • • Β2-Microglobulin amyloidosis: Pts >50 yrs old. joints. bone fx’s. • Pts w/ amyloidosis have ↑ mortality rates . carpal tunnel. GI perfs. rotator cuff tears. Complications. bones. on dialysis >10 yrs Amyloid deposits in GI tract.

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 graft: higher complication rates. Hickman. • 3. Tunnel-cuffed catheters. Quinton . A-V fistula • 2.Vascular Access Complications • Types of Access: • 1. shorter functional lifes.

.• • • • Thrombosis and Stenosis of Access: Most common complication Loss of bruit and thrill Stenosis / thrombosis: not Emergencies= tx w/in 24 hours.

• Vascular Access Infections: • 2-5% of fistulas. . Hypotension. fever. swelling. discharge at site often missing. usually add Gent. • Staph Aureus #1. ↑ WBC • Erythema. 10% of grafts • Often signs of sepsis. gram neg #2 • Vanc is drug of choice.

anastomosis rupture or over anticoagulation.01 mg/unit hep. • Consult surgery or nephrology . • Direct pressure • Protamine 10-20 mg or 0.• Hemorrhage: • d/t aneurysm.

• • • • • Vascular access aneurysms: Repeated punctures Bulging in wall Rarely rupture True aneurysms very rare. 4% of fistulas .

• Vascular access pseudoaneurysm: • Subcutaneous extravasation of blood • Present w/ bleeding & infection at site .

cool pulseless digits • Dx w/ doppler or angiography .• Vascular insufficiency: distal to access • “steal syndrome” • Preferential shunting of blood to low pressure venous side • s/s exercise pain. non-healing ulcers.

.• 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.

10-20% of treatments Dialysis can remove up to 2 L/hr. anit HTN meds. sepsis. Hypotension: Most frequent. Cardiac compensation limited d/t ↓ diastolic function common in ESRD • Abnormalities in vascular tone. ↑ nitric oxide .Complications During Hemodialysis • • • • 1.

d/t sepsis. diarrhea. cardiac or pericardial disease. vomiting. GI bleed.• Early hypotension: pre-existing hypovolemia • Peridialysis losses. decreased salt/water intake • Intradialytic blood loss from tubing/dialyzer leads • Hypotension at end of dialysis: excessive removal. . starts HD below dry weight.

• Tx. dizzy. tachycardia. Salt. • If these fail look for other causes than excessive fluid removal . NS 100-200 cc. ortho hypotension. Trendelenburg. broth by mouth. IV.. stop HD. syncope.• Intradialytic hypotension: • N/V/anxiety.

HTN..• 2. Stop HD. seizure and death • d/t cerebral edema after large solute clearance in HD • Tx.progress to coma. Dialysis disequilibrium: • End of dialysis • N/V. .. administer Mannitol IV.

hyperbaric O2 treatment . full heparinization. full cardiac arrest. IV steroids. chest tightness. Cyanosis. Air Embolism: • s/s: dyspnea.• 3. churning sound in heart from bubbles • Clamp venous blood line. place supine • Other Tx’s: percutaneous aspiration from R ventricle. unconscious.

• 4. burning skin. weakness. ↑Mg • N/V. HA. lethargy HTN • 5. Hypoglycemia . Electrolyte abnormalities: • ↑ Ca.

high flow d/t anemia? . • Peripheral edema. HJR. swelling. erythema. JVD not always CHF • Murmurs.Evaluation of HD Patients • • • • Dialysis schedule Dry weight Length of dialysis Inspect access site. discharge. tender.

Peritoneal Dialysis • Peritoneal membrane= blood-dialysate interface • Can be done acutely. . chronically (continuous)=4 times/day. or multiple exchanges at night while sleeping.

abd pain. aureus 10%. S.5 % Fever. anaerobic bacteria 5%. .Complications • • • • Peritonitis #1 Mortality 2. gram neg bacteria 15-20%.5-12. Gram stain. Strep species 15-20%. rebound tender Dialysate fluid for cell count. fungi 5%. culture • Staph epidermidis 40%.

• • • • 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 .

discharge. aureus. swelling. S.• • • • • Infections around PD catheter site: Pain. Pseudomonas aeruginosa Empiric w/ first generation Ceph or Cipro Outpatient therapy with f/u at CAPD center next day . erythema.

• • • • Abdominal wall hernia 10-15% Highest rate of incarcerating Immediate surgical repair .

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: • 1. T/F Troponins are commonly significantly elevated in patients on regular dialysis and cannot be trusted as cardiac marker. is rarely seen in ESRD pts on dialysis. • 3. T/F Peripheral Neuropathy. . “stocking and glove pattern”. • 2. T/F ESRD patients carry the same cardiovascular risk as general population.

staph aureus – C. #1 cause of dialysis access site infections… – A. E. strep species – D. coli .• 4. klebsiella – B.

cough Answers: false (seen in 50%). A.• 5. – A. . B. false(inc risk). false. #1 complication during dialysis sessions is …. fever – C. hypotension – B. CHF – D.