failure occurs when the kidneys
are unable to do their job: to filter
wastes from the blood, help regulate
blood pressure, and regulate salt
and water balances in the body. As
blood flows through the kidneys, it
is filtered, and wastes are removed
and sent to the bladder as urine.
renal failure (CRF) requiring dialysis or
transplantation is known as end-stage renal
disease (ESRD). In the United States, diabetic
nephropathy, hypertension, and glomerulonephritis
cause approximately 75% of all adult cases.
Certain geographic areas have a high incidence
of HIV nephropathy.
with ESRD are commonly encountered in the
ED with problems related to the metabolic
complications of their renal disease or
dialysis complications. Various problems
related to vascular access in patients on
hemodialysis and to abdominal catheters
in patients taking continuous ambulatory
peritoneal dialysis (CAPD) are also common.
Patients who have undergone renal transplantation
may experience a variety of transplant-related
with CRF may present to the ED with an unrelated
condition. In these cases, the level of
renal function may have important implications
for diagnosis and treatment.
major organ systems are affected by renal
failure. Prevalence of symptoms is a function
of the glomerular filtration rate (GFR),
which averages 120 mL/min in a healthy adult.
As the GFR falls to less than ~20% of normal,
symptoms of uremia may begin to occur. They
almost are invariably present when the GFR
decreases to less than 10% of normal.
and symptoms of renal failure are due to
overt metabolic derangements resulting from
inability of failed kidneys to regulate
electrolyte, fluid, and acid-base balance;
they are also due to accumulation of toxic
products of amino acid metabolism in the
serum. Signs and symptoms include the following:
weakness, and fatigue are very common.
disturbances include anorexia, nausea,
vomiting, and hiccups. Peptic ulcer
disease and symptomatic diverticular
disease are common in patients with
neuropathy and restless legs syndrome
are the most common neurologic complications
is inevitable in CRF because of loss
of erythropoietin production. Abnormalities
in white cell and platelet functions
lead to increased susceptibility to
infection and easy bruising.
is a common dermatologic complication
assumed to be secondary to accumulation
of toxic pigments (urochromes) in the
overload, a common cardiovascular complication
of renal failure, occurs when salt and
water intake exceeds losses and excretion.
Hyperkalemia is the most common immediately
life-threatening metabolic complication
of renal failure and may develop suddenly
when GFR is severely reduced. Anion
gap acidosis results from decreased
hydrogen ion excretion and may exacerbate
hyperkalemia. Hypocalcemia is potentially
life threatening and results from loss
of vitamin D and increased parathyroid
hormone levels. Hypermagnesemia also
access complications are similar to
those seen in any patient with a vascular
surgical procedure (eg, bleeding, local
or disseminated intravascular infections,
vessel [graft] occlusion).
peritoneal dialysis catheter subjects
patients to the risks of peritonitis
and local infection. The catheter acts
as a foreign body and provides a portal
of entry for pathogens from the external
who have received renal transplants
may experience recurrent renal failure
due to rejection or other graft complications.
In addition, chronic immunosuppression
makes them prone to infection.
the US: The government of the United States
funds treatment of ESRD universally for
US citizens. As a consequence, the population
of patients receiving dialysis or who have
had a renal transplant in the United States
is large. Approximately 150 cases of CRF
per million persons are newly diagnosed
per year in the United States. Approximately
half of these patients go on to require
dialysis or transplantation. As a result,
patients with ESRD are encountered on a
regular basis in most US EDs.
allocated for treatment of ESRD vary throughout
the world. Very few patients with ESRD are
encountered in countries where ESRD treatment
is not funded by the government because
of the high mortality rate when dialysis
or transplantation is not widely available.
in renal failure are prone to all of the
complications of any underlying condition,
such as diabetes and hypertension. In addition,
renal failure causes a variety of metabolic
and physiologic derangements.
most common cause of sudden death in patients
with ESRD is hyperkalemia, which is often
encountered in patients who have missed
dialysis or commit dietary indiscretion.
Serum potassium also rises when the serum
is acidemic, even though total body potassium
is unchanged. Hyperkalemia is usually asymptomatic
and should be treated empirically when suspected
and when arrhythmia or cardiovascular compromise
is present. Iatrogenic complications related
to fluid administration (fluid overload)
or medications are frequently encountered
in patients in renal failure.
of ESRD differs among racial groups primarily
because of the prevalence of predisposing
conditions, such as diabetes and hypertension.
In populations with problematic access and
utilization of primary medical care for
treatment of predisposing conditions, ESRD
often is encountered in relatively young
patients. While the costs of treatment for
ESRD are borne by the entire population
(through government funding), relatively
inexpensive preventive treatments often
are funded poorly. Diseases such as diabetes
and hypertension are much less likely to
lead to renal failure when appropriately
treated. The cost of primary care for these
conditions is far lower than for dialysis
or transplantation, yet primary care remains
poorly funded while ESRD treatment is reimbursed
completely by the government. This conundrum
is reflective of the often illogical and
capricious nature of health care spending
in the United States.
Presentation and treatment of CRF and ESRD
do not differ significantly between men
and women. Differences in causes of renal
failure are related to the types of underlying
conditions prevalent in men and women.
While the etiology of CRF differs
among age groups, the presentations and
nature of complications are similar. Young
children with ESRD often are treated with
transplantation because of difficulties
related to vascular access for dialysis.
hemodialysis access sites may be used
to draw blood or infuse medications
and fluids in an emergency when no other
access is available.
- A central venous
access device may be used with the usual
- The following
procedure may be used when hemodialysis
access is used in an emergency:
- Do not use
- Avoid puncturing
the back wall of the vessel.
- Carefully secure
all IV catheters; infusions may need
to be under pressure because of relatively
high pressures at the access site.
- Apply firm
but nonocclusive pressure for 10-15
minutes after accessing a peripheral
hemodialysis access site.
- Document presence
of a thrill before and after procedure.
- A patient with
ESRD who has no residual urine output
may have a lower urinary tract infection
(a pus filled bladder is known as pyocystis).
- Consider bladder
catheterization in patients with ESRD
who present with fever or lower abdominal
- If purulent
material is obtained, send it for culture.
an immediately life-threatening emergency,
prehospital personnel may use a hemodialysis
access site for IV access with the precautions
noted in Procedures. The site should
not be used for routine IV access.
IV fluids should not be administered
except for cases of frank shock. When
used, the preferred regimen is small
bolus doses (~200-250 mL) with reevaluation
for effect between doses. Lactated Ringer
solution should not be used because
of the potassium content.
Most medications used in prehospital
care are used in the usual dosages.
Do not give diuretics in the field to
dialysis patients with ESRD. They usually
are not effective and may have more
than the usual toxicity.
Cardiac arrest in a patient with CRF
or ESRD may be due to hyperkalemia.
Consider treatment with IV calcium and
patients with CRF or ESRD or in transplant
recipients generally are treated as in
all other patients. Certain conditions
are unique to this group of patients,
and others occur more commonly than in
patients with normal renal function.
arrest in patients with CRF or ESRD
may be due to hyperkalemia. In most
medical arrests, treat hyperkalemia
empirically with IV calcium and bicarbonate
while awaiting laboratory confirmation.
pericardial tamponade, especially in
the setting of pulseless electrical
activity (PEA). Consider pericardiocentesis
if tamponade is suspected.
edema is frequent in renal failure and
usually is due to volume overload. Also
consider myocardial dysfunction.
- Volume overload
is best treated by hemodialysis
or by use of hypertonic dialysate
in CAPD patients.
administered by the sublingual,
topical, or IV routes are effective
in the usual doses.
- Loop diuretics
(eg, furosemide) may be effective
at promoting diuresis in patients
with residual renal function. They
also may be effective because of
a pulmonary venodilation effect.
Ototoxicity is potentially increased
because of delayed excretion and
higher blood levels.
- IV morphine
is useful for its vasodilating effects.
Take care to avoid precipitating
in patients with renal failure (as in
other patients) usually requires no
treatment in and of itself.
- When indications
for treatment exist, such as myocardial
ischemia or hypertensive encephalopathy,
usual treatments may be used with
appropriate dosage adjustment.
Dialysis may be needed if hypertension
is due to volume overload.
Nitroprusside may be used to treat
severe hypertension in patients
with renal failure. Risk of thiocyanate
toxicity is increased and levels
must be monitored in cases of prolonged
Hypotension in dialysis patients may
be due to any of the causes encountered
in any other patient. Consider serious
causes such as bleeding, cardiac dysfunction,
and sepsis. The most common cause is
dialysis. After more serious causes
are ruled out, IV isotonic saline in
small bolus doses (~200 mL) may be used
Bleeding may be due to uremic coagulopathy
or from anticoagulation during hemodialysis.
In the latter case, the heparin effect
may be reversed with protamine.
Desmopressin (DDAVP) by nasal, subcutaneous,
or IV routes and cryoprecipitate
are effective in correction of uremic
Applying firm but nonocclusive pressure
for 10-15 minutes best treats bleeding
from a vascular access site.
CAPD-associated peritonitis is treated
with a loading dose of parenteral antibiotic
followed by a period of intraperitoneal
antibiotics. Most institutions that
treat CAPD patients have a standard
protocol for treatment.
Cutaneous herpes zoster infection in
renal transplant patients should be
treated with systemic antiviral therapy
to prevent or ameliorate possible dissemination.
with a nephrologist and/or vascular surgeon
for the following problems:
for urgent dialysis
Signs of transplant rejection, infection,
Significant deterioration from baseline
CAPD-associated peritonitis or catheter-associated
Infection, obstruction, or expanding
aneurysm/pseudoaneurysm of the vascular
Changes in calcium and phosphorous metabolism,
hyperkalemia, hyponatremia, acidosis
Hypothyroidism, seizures, fractures
Infertility, impotence, spontaneous
Bleeding, GI mucosal ulcerations, arteriovenous
is approximately 20% despite careful attention
to fluid and electrolyte balance or other
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