1. Renal Failure and Complications of Hemodialysis Paul B. Jones PGY3 – May 8th

2. Objectives  Define renal failure  Review ED management of acute renal failure  Review indications of dialysis  Review complications of dialysis  Review some 1A pearls

3. 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.

4. ED Goals  Treat underlying cause  Correct fluid derangements  Correct electrolyte derangements  Prevent further renal damage  Provide supportive care until renal function recovers

6. 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.

7. 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…

8. 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

9. 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.

10. 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.

11. AEIOU  Acidemia  Electrolyte derangement  Intoxication/poisoning with dialyzable substance  Overload of fluid  Uremic complications

12. Any sometimes why?

13. Hemodialysis

14. Key Elements for Dialysis  Dialyzer membrane  Access  Anticoagulation

15. Dialyzer Membrane

16. 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

17. Anticoagulation

18. 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?

19. Hemodialysis Complications  Vascular access related complications  Bleeding  Vessel Thrombosis  Infection  Non-vascular complications  Hypotension  Acute hemorrhage  Severe hyperkalemia

20. Uremia

21. Complications of HD  Hypotension  Dialysis Disequilibrium  Air Embolism  Electrolyte Abnormalities  Hypoglycemia

22. 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)

23. 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)

24. 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)

25. 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

26. 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.