Question 8

Outline the pathophysiological changes associated with end-stage kidney disease (dialysis dependent) that may impact on the management of critically ill patients.

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College answer

Not available.

Discussion

Renal:
Low/no urine output

Metabolic and Endocrine:
Associated
o   Hyperkalaemia
o   Abnormal Ca++
o   Hyperphosphataemia
Need for dialysis determines fluid prescribing, feeding and any protein restriction

Cardiovascular:
Hypertension very common
Atherosclerosis common
Pericarditis common

Respiratory:
Prone to pulmonary oedema

Neurological:
Dialysis disequilibrium

Polyneuropathy and myopathy

Skin:
Fragile skin

Haematological:
Anaemia
Platelet dysfunction

Gastrointestinal:
Impaired gastrointestinal motility
Increased risk of bleeding related to gastric ulceration

Immunological:
Increased risk of infection

Pharmacological:
Altered clearance of medications that have predominant renal excretion

Vascular access:
Fistulas used for dialysis may complicate CVC and arterial access

Other issues specific to ESRD: 

  • The central veins draining the access arm with the fistula should be protected from venous
    catheters
  • Diet should be potassium- and phosphate-restricted
  • An AV fistula should not be accessed for CRRT or SLEDD, because the sessions are long and the risk of needle dislodgement and lifethreatening haemorrhage is thus greatly increased.
  • In terms of small solute clearance, there is no need to change the dose of dialysis in critically ill ESRD patients when compared to their regular maintenance dose.
  • Hypotonic and hypertonic fluids should be avoided

References

Clermont, Gilles, et al. "Renal failure in the ICU: comparison of the impact of acute renal failure and end-stage renal disease on ICU outcomes." Kidney international 62.3 (2002): 986-996.

Szamosfalvi, Balazs, and Jerry Yee. "Considerations in the critically ill ESRD patient." Advances in chronic kidney disease 20.1 (2013): 102-109.

Arulkumaran, N., N. M. P. Annear, and M. Singer. "Patients with end-stage renal disease admitted to the intensive care unit: systematic review." British journal of anaesthesia 110.1 (2013): 13-20.

Thompson, Stephanie, and Neesh Pannu. "Renal replacement therapy in the end-stage renal disease patient with critical illness." Blood purification 34.2 (2012): 132-137.