Emergency medicine evaluation and management of the end stage renal disease patient

Am J Emerg Med. 2017 Dec;35(12):1946-1955. doi: 10.1016/j.ajem.2017.09.002. Epub 2017 Sep 5.

Abstract

Background: End stage renal disease (ESRD) is increasing in the U.S., and these patients demonstrate greater all-cause mortality, cardiovascular events, and hospitalization rates when compared to those with normal renal function. These patients may experience significant complications associated with loss of renal function and dialysis.

Objective: This review evaluates complications of ESRD including cardiopulmonary, neurologic, infectious disease, vascular, and access site complications, as well as medication use in this population.

Discussion: ESRD incidence is rapidly increasing, and patients commonly require renal replacement therapy including hemodialysis (HDS) or peritoneal dialysis (PD), each type with specific features. These patients possess greater risk of neurologic complications, cardiopulmonary pathology, infection, and access site complications. Focused history and physical examination are essential. Neurologic issues include uremic encephalopathy, cerebrovascular pathology, and several others. Cardiopulmonary complications include pericarditis, pericardial effusion/tamponade, acute coronary syndrome, sudden cardiac death, electrolyte abnormalities, pulmonary edema, and air embolism. Infections are common, with patients more commonly presenting in atypical fashion. Access site infections and metastatic infections must be treated aggressively. Access site complications include bleeding, aneurysm/pseudoaneurysm, thrombosis/stenosis, and arterial steal syndrome. Specific medication considerations are required for analgesics, sedatives, neuromuscular blocking agents, antimicrobials, and anticoagulants.

Conclusions: Consideration of renal physiology with complications in ESRD can assist emergency providers in the evaluation and management of these patients. ESRD affects many organ systems, and specific pharmacologic considerations are required.

Keywords: Bleeding; Chronic kidney disease; Continuous ambulatory peritoneal dialysis; Encephalopathy; End stage renal disease; Hemodialysis; Uremia.

Publication types

  • Review

MeSH terms

  • Emergency Medicine
  • Humans
  • Kidney Failure, Chronic / diagnosis*
  • Kidney Failure, Chronic / physiopathology
  • Kidney Failure, Chronic / therapy*
  • Peritoneal Dialysis, Continuous Ambulatory*
  • Renal Dialysis*
  • Renal Replacement Therapy*
  • Risk Assessment
  • Time Factors
  • Treatment Outcome
  • United States